A series of cascading factors: a breakdown in communication between 911 and EMS, the inability to communicate with emergency services and a lack of available ambulances delayed medical assistance by more than 30 minutes for an elderly person in Calgary who had been attacked by dogs.
The Health Quality Council of Alberta released an independent report Thursday detailing the emergency response to the fatal dog attack. Betty Ann (Rusty) Williams, 86, was mauled by three dogs while gardening in the city’s Capitol Hill neighborhood last June.
It took an ambulance 36 minutes to reach 86-year-old Betty Ann Williams, who had been attacked by three dogs in the city’s Capitol Hill neighborhood. He died from his injuries. (McInnis and Holloway Funeral Homes)
Your neighbors described in CBC News how they held the woman for about half an hour, next to a law enforcement officer, while they waited for an ambulance.
The incident prompted scrutiny of AHS’s wait times.
Charlene McBrien-Morrison, CEO of the Health Quality Council of Alberta, said there was no single action or activity that caused the ambulance to be delayed.
“It was a confluence of many things that came together that day … some more significantly than others.”
He said there were communication protocols, but they weren’t being used properly: “the tools that were there were misunderstood or misused.”
The report from HQCA, a provincial agency that operates independently of Alberta Health Services and Alberta Health, said EMS arrived 36 minutes and nine seconds after the 911 call.
The event was initially coded as non-life threatening.
The Calgary 911 caller, with information that there had been an attack involving a dog, assumed the scene was unsafe and assigned police rather than EMS as the lead agency.
EMS dispatch did not speak directly to the 911 caller.
The report also found that the 911 call taker communicated information to EMS in a manner that did not follow an established process. EMS, in turn, used a manual card for dog attacks instead of a computerized version. If they had been using the computer program, it would have raised questions about the elderly person’s condition.
If the response had been upgraded to life-threatening, the report estimated that paramedics would have been on the scene shortly after 14 minutes.
However, this would still have exceeded AHS’ target response time for life-threatening incidents.
The report noted that the southern Alberta communications center was understaffed that day and demand for EMS exceeded available resources. Only 31 of 38 (or 82%) ambulances assigned to Calgary were staffed, and EMS was on red alert, meaning no ambulances were available to respond to events.
Mauro Chies, interim president of AHS, said the event has had a far-reaching impact on those involved.
“We deeply apologize for the role AHS played in bringing the ambulance to the scene that day,” he said.
A law enforcement officer arrived on the scene within minutes. He tried to make several calls to EMS, but was unable to do so. Once EMS arrived, they went to the wrong place: in front of Williams’ house, not in the alley.
EMS dispatch move caused ‘tension’
HQCA said moving EMS dispatch to a separate location appears to have led to “tension” between that agency and Calgary 911.
“When AHS EMS moved to a different physical location, many reported that the relationship between the agencies became strained,” the report said.
But the report said that shipment consolidation was not found to have contributed to the outcome of this incident or to have contributed to response times.
“Whether people are in the same room or not, everyone is incredibly busy in that room. And their respective people are getting calls from their respective services. So to assume that sitting together would have solved that, I think, is not something that we would have considered appropriate,” said McBrien-Morrison.
The HQCA prepared recommendations for AHS, the City of Calgary and the Calgary Police. AHS has said it will act immediately and implement its recommendations.
To address incorrect coding and the inability of the bylaw officer to provide scene information, HQCA recommends revising Calgary 911’s policy on scene safety assessment, improving the collection of ‘patient information and creating or updating policies to allow law enforcement officers to intercept radio traffic. .
He also recommended improving co-evaluation between 911 call takers and EMS, which is when the agencies evaluate a call together.
Other recommendations relate to ways to address demand for EMS that exceeds available resources, including diverting more calls to other EMS call centers in Alberta.
The Calgary Police Service said it has reviewed the HQCA report and will consider its own response.
The statement said the report made recommendations on the use of a secondary emergency dispatch notification (SEND). The police service said its members were trained in SEND in February 2021.
SEND is a protocol intended to streamline communication between emergency personnel in the field and dispatchers.
However, HQCA said CPS communicated internally about the SEND protocol but “no confirmation has been obtained to indicate that front-line officers (CPS or statutory) are trained to use the SEND protocol”.
Early response to trauma is important, says doctor
Dr. Ian Walker, emergency room physician and medical director of AHS EMS, said he doesn’t know if the extra time would have saved Williams, but added that earlier response is better in treating trauma.
“The sooner we get trauma patients in, the better they do, as a general rule.”
The three dogs that attacked Williams were an American pit bull terrier mix, an American Staffordshire mix and an American pit bull. They were owned by a neighbor.
In October, Calgary police, in consultation with the Crown prosecutor, determined that the necessary elements were not met to support a charge of criminal negligence causing death against the dogs’ owners.
The HQCA report was originally scheduled for September, but was delayed until January due to its complex nature.