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

by Prince Of Petworth July 29, 2015 at 3:10 pm 11 Comments

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.”


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