D.C.’s embattled 911 call center needs to be more transparent with the public, particularly in incidents during which mistakes were made, to help regain public trust, auditor Kathy Patterson said Thursday.
A new report, a second status update on how the Office of Unified Communications is faring in implementing recommendations from a 2021 audit, said that while the agency is making some progress, more transparency is needed.
In making the call for additional accountability, Patterson released a 911 call from an October 2022 incident. The caller explained a roommate was on the floor and not responding to calls for his name.
But over the two-plus minute conversation, the operator never asked if the person was breathing, Patterson said. As a result, it took 20 minutes for responders to arrive. The resident died of cardiac arrest.
In the aftermath of the incident, according to a news release, the agency posted a “final report” on its website that called it a “life assist” instead of a medical emergency.
It didn’t include a description of the error, Patterson said.
D.C.’s Office of Unified Communications has been scrutinized for delays in its responses and, in some instances, sending emergency personnel to wrong addresses.
Many of the agency’s troubles stem from leadership and supervision, Patterson said, pointing to that as one of the key findings of the October 2021 audit.
Mayor Muriel Bowser has appointed Heather McGaffin acting director of the agency. Karima Holmes withdrew her name from consideration last year, after several council members expressed opposition to her leadership.
McGaffin is awaiting a D.C. Council confirmation hearing.
“You can’t rebuild trust if you’re continuing to not acknowledge mistakes, and therefore not hold people accountable, and not correct the mistakes going forward,” Patterson said.
The agency, according to the follow-up report, should be required to share more information, including “de-identified” after-action reports that should be posted online within 10 days of an incident. Audio files should also be available upon request.
“None of us is perfect, just yet,” Patterson said. “We all make mistakes. In the case of [the October 2022] call taker, that’s a mistake that should not be made. The call taker failed to pick up on cues that were given by the caller of a victim.”
The OUC, Patterson said, created a new policy related to incident reporting in November. But, she said, the audit team found the incident reporting process is “not robust enough, doesn’t have deadlines, doesn’t have timelines, they’re not releasing information.”
The agency also said it would now have four supervisors on duty per shift, which Patterson said would be positive news if “they’re not misstating that.”
In a response to Patterson’s follow-up report, McGaffin, the acting director, said that to date, 23 of 30 recommendations from the audit are complete. The agency, McGaffin wrote, has hired more supervisors for each shift, adjusted its training processes and started using new technology, among other things. It’s also increased staffing on all shifts.
The OUC, McGaffin said, anticipates implementing the remaining recommendations by the end of the summer.
McGaffin also said some responses to the original audit are no longer relevant because “this audit has now spanned three directors.”
“As you can see in the March 2023 Roadmap Update, we have made much more progress on many original recommendations than the five-month-old review attests to,” McGaffin wrote.
But, Patterson said, “There’s a ways to go here in demonstrating that the agency understands the depth of some of the issues and is going to correct them. And you just can’t do that without being honest about mistakes when they’re made.”
