Mayor Announces Emergency Response Reforms After Technical and Software Error Results in Delayed Response to 1 Year Old Baby in Distress

Photo by PoPville flickr user D.B.

From the Mayor’s Office:

“Mayor Muriel Bowser announced reforms at the DC Fire and Emergency Medical Services Department (FEMS) and the Office of Unified Communications (OUC) that will improve emergency response times and quality of care for residents and visitors to the District.

The reforms come as FEMS released an investigative report on the delayed emergency response that occurred March 13, 2015 in Tenleytown. That day, at approximately 8:36 a.m., OUC received a 911 call for a one year old male in distress. Paramedics arrived on scene at 8:47 a.m. and provided advanced life support care, but unfortunately the child subsequently died.

Mayor Bowser tasked FEMS and OUC with conducting a top-to-bottom review of the incident, as well as their overall emergency response processes and procedures. The months-long internal investigation found that human error along with technological and training issues – related to a new dispatch system – contributed to a breakdown in emergency response communications.

A redacted version of the FEMS report can be found HERE.

Due to a technical and software error, OUC did not recognize the nearest FEMS unit to the child’s residence and, as a result, the nearest FEMS unit was not dispatched. A FEMS lieutenant at the Tenleytown Fire Station failed to alert OUC of this fact and the availability of his unit.

Following the internal review, FEMS found the lieutenant to be in violation of department policy. Specifically, the lieutenant violated Article VII Section 2 (f) of the FEMS Order Book: “Any on-duty or employment-related act or omission that interferes with the efficiency and integrity of government operations.” In this case, the violation includes neglect, incompetence, and unreasonable failure to give assistance to the public. The lieutenant’s conduct has been sent to a Trial Board for disciplinary action. Pursuant to District personnel policy, the lieutenant’s name will not be publicly released.

“My top priority is the safety and wellbeing of our residents,” said Mayor Bowser. “I appreciate the thorough investigation conducted by Chief Gregory Dean and Director Chris Geldart to uncover the issues surrounding the tragedy on March 13. They have developed an action plan and I will hold my agencies accountable for following through and delivering for residents and visitors.”

“Mayor Bowser tasked FEMS to get to the bottom of what happened on March 13th and fix our processes so that it never happens again,” said FEMS Chief Dean, who assumed his position on May 4. “We are working around the clock to ensure our FEMS emergency response services work for the District of Columbia and our residents.”

Since March 13, the Bowser Administration has implemented the following reforms to improve response times and deliver higher-quality care for those in need.

Installed New Leadership at FEMS & OUC

Mayor Bowser has put in place new leadership to strengthen FEMS and OUC. In May, Chief Dean began a six-month process of reviewing and evaluating FEMS services to understand current operations and identify areas for improvement. In June, Chris Geldart, the District’s Homeland Security and Emergency Management Agency Director was tasked with reforming OUC and partnering with FEMS on EMS dispatches. This month, FEMS re-created the position of Assistant Chief of Emergency Medical Services and recruited Dr. Juliette Saussy, a nationally-known and experienced EMS leader, to be the new FEMS Medical Director.

Initiated Software and Operational Changes to Improve OUC Tablet Operability

In response to the breakdown in tablet technology, OUC implemented several software patches to improve connectivity, accuracy, and reliability. In addition, network connectivity of tablets is now monitored hourly, which allows OUC and FEMS to identify and resolve issues in almost real time.

Built Redundancy into FEMS Policies to Minimize Chances of Human or Technical Errors

As a redundancy measure in the event there is an error with the automatic dispatching system and the closest available FEMS unit is not dispatched, FEMS issued a new policy requiring units to announce themselves on the radio when another unit is closer to a call than the unit that has been dispatched. This will ensure that the closest available unit is responding to an emergency call.

Delivered Additional Reforms

FEMS and OUC have implemented additional reforms to improve the overall quality of service for District residents.

FEMS and OUC are filling vacancies and fully staffing every shift to improve quality of EMS delivery. At FEMS, 27 firefighter-EMTs with previous training and experience recently graduated from the Academy and have been deployed. 17 new firefighter-EMTs from the FEMS Cadet Program entered the service in April. And by mid-September, 17 new Firefighter-Paramedics will be deployed in service of DC residents. For the first time in years, FEMS offered exams to recruit new firefighter-EMTs; approximately 4,000 applicants took the test, of which almost half were District residents. The Department will soon publish a hiring registry based on the exam results, from which future classes of firefighter-EMTs will be hired.

After an analysis conducted earlier this year by the Deputy Mayor for Public Safety and Justice, FEMS placed up to 10 additional ambulances in service on weekdays to keep pace with growing demand for service – resulting in fewer instances where no ambulances are available to transport patients.

Mayor Bowser proposed a significant increase in the FEMS proposed capital budget for FY 2016 and beyond. This will allow the Department to purchase additional emergency vehicles. And the purchase of new vehicles will be guided by the replacement schedule recommended by the 2013 BDA Global Audit and Assessment Report, at least through FY 2017.

Finally, FEMS is utilizing Hospital Liaison Officers at three local hospitals to help ambulance crews return to service more quickly after transporting a patient to the hospital.”

11 Comment

  • What a tragedy. I have heard a co-worker and a neighbor once tell me how frightfully long it took to get a 911 call answered (more than 3 minutes) and EMS didn’t come quick enough and even bungled the address. I don’t want to freak ya’ll out even more, but its a mess.

    • Totally agree. I once saw a package theft in progress on my block and called 911 immediately. By the time an operator answered several minutes later, the two guys were more than long gone. I told the dispatcher I had photos of the guys and no one followed up with me about it.

  • I needed an ambulance a few weeks ago. My boyfriend was hung up on multiple times by dispatch. (supposedly the office of communications is investigating the incident…) . It took 4 calls to get someone to stay on the line and confirm an ambulance was coming. We were playing softball by the Washington monument, dispatch would not accept the Washington monument as a location point for our spot on the national mall, and repeatably kept demanding an address. It took 18 minutes for an ambulance to come. Luckily I was not in mortal danger, but did have head trauma (broken and fractured bones) . Is 18 minutes normal?? GW hospital was so close is seemed insane. I tried searching and could only find DC’s target times for “critical medical calls,” which I was guessing I didn’t quite qualify for.

    • west_egg

      Completely unacceptable. I guarantee you the reason they kept demanding an address is because of limitations in their software that won’t allow them to dispatch without that information. I’ve heard multiple reports like this–another from a person standing at an intersection but they wouldn’t dispatch without an address. It’s criminal that this has not been addressed.

  • I hope and pray that if I ever need the response of an ambulance or a fire truck, that I am nowhere near the District of Columbia.

  • west_egg

    I’m infuriated by the incompetence on display at DC FEMS and our 911 dispatch center, and I have ZERO faith in Mayor Bowser’s “reforms.” From the Washington Post on June 18:
    “The D.C. fire department has failed to implement more than a dozen revisions recommended after a mugging victim died nearly 10 years ago because emergency crews dismissed him as drunk and treated the call as a low priority, the city’s auditor concluded Thursday.”
    Ten years! After that long I can’t help but conclude that DC FEMS is beyond repair and that our city’s leadership has no interest in making improvements. As a resident of Ward 4 I can tell you that reform is not something Ms. Bowser is known for. Mugging victims get mistaken for drunks; heart attack victims die on the street across the street from fire houses; 911 can’t keep track of its vehicles and can’t find the Washington Monument. God help me if I’m ever in trouble.

  • My sincerest condolences to the family of this little boy. Losing a child is quite possibly the worst thing anyone can endure. I’m so very sorry.

  • I once called 911 to report two people obviously high out of their minds in front of my house. They were falling down in the street, vomiting, screaming into the night sky, and headbutting parked cars and trees. The 911 operator asked me literally 3 or 4 times to describe them, whether they had weapons, what drugs they were using (I would know this how??), and why I thought they were committing crimes. I explained that however you want to describe it, there are people vomiting in the street and smashing their faces against cars. I said that I thought the police might like to know about this before someone is injured. The operator asked me again if the people had a weapon, and what kind of weapon it is, so I just hung up.

  • anyome knows the response time here is completely unacceptable in an urban environment. The fact that we, as a city, continue to use 911 for non emergency services is just a cluster. I work in the law enforcement field and I’m terrified what would happen if I ever needed 911.

  • One is advised to say “I “think” he/she has a weapon, or, “Yes!, It appears the person has a weapon”. It ups the call to priority…that is if they don’t disconnect you

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