Last week, a 3-month-old boy named Aaron Boyd Jr. died after being trapped in a car and going into apparent cardiac arrest. Though police officers got there sooner, a dispatching error meant it took 13 minutes for paramedics to arrive to the scene where the boy died, the Washington Post reported — a wait time that Deputy Mayor for Public Safety and Justice Chris Geldart described to the outlet as “too long” and “outside the norm of what we can expect.”

It’s unclear if the dispatching delay contributed to Aaron’s death, but officials at the Office of Unified Communications – the agency in charge of taking emergency calls and dispatching first responders in the city – are investigating the incident.

Geldart also told the Post that the city was considering transferring dispatch responsibilities from OUC to the fire department — but D.C. Mayor Muriel Bowser later walked back his statement, telling reporters “that’s not the case.”

“The Office of Unified Communications (OUC) expresses our sincere condolences to the family who lost their infant,” a department spokesperson wrote in an emailed statement. “OUC handles a combined 3.5 million 911 and 311 calls annually and takes very seriously its role in helping to maintain public safety for the residents of the District of Columbia.”

This latest incident is part of a series of 911 mistakes that has advocates, residents, and D.C. councilmembers concerned about the city’s emergency response system. While the agency has been praised in recent years for implementing new technology, including launching a text to 911 system, it has also been heavily scrutinized over its performance — including issues with call response time and high-profile incidents where employees failed to accurately locate callers in dire emergencies. An independent review of the agency commissioned by the D.C. Auditor and published last year found that OUC fell short of national standards.

By the count of retired journalist and public safety advocate Dave Statter, who has been covering issues with D.C.’s emergency response system for decades, this most recent incident was the ninth time in three years that 911 errors led to delayed emergency responses in incidents where a person died.

Statter spends a lot of his time focused on OUC. The office opened in 2001 in response to scathing news reports — some of which Statter authored — and an inspector general’s report that found a multitude of problems with the city’s 911 call system. Among other issues — including concerns about the way callers were being spoken to by 911 call-takers — the reports criticized the amount of time it took for operators to answer 911 calls. The inspector general, for example, found that one in five 911 calls was answered within 16 to 80 seconds — and one in eight calls did not receive an answer at all.

Now, decades later, advocates, residents, and D.C. Councilmembers say D.C.’s 911 system still has serious problems.

Statter spoke with DCist/WAMU about this latest tragedy, and what he’s learned through his years of following 911 in the District. The following interview has been lightly edited and condensed for clarity.

DCist/WAMU: Let’s start with the basics. Can you explain how DC receives 911 calls and then dispatches resources? 

Dave Statter: The 911 center is part of the Office of Unified Communications, which also runs 311.

They have call-takers who receive the 911 calls, put it in the computer system, then either a supervisor or a dispatcher looks at it and makes sure it goes into the computer system to be dispatched. The computer picks the closest Fire and EMS companies, and then it’s all dispatched to the firefighters and paramedics and EMTs in the city for them to respond. The dispatcher then stays in contact with the Fire and EMS units on the radio and gives them information.

The breakdown in this process can often start with a call-taker who is having a tough time figuring out where this person is located. Because in my experience, there [can be a lack of knowledge about] geography and landmarks in the city. They don’t know the city as well as they should. There are a lot of mistakes that happen when they choose the wrong address.

Let’s focus on this most recent possible 911 mistake from last week. What exactly happened with this three-month-old boy, Aaron Boyd Jr., in Northwest D.C.?

Unfortunately, this most recent case is one of the worst I’ve heard. There were two major mistakes, according to sources I have within OUC and the other government agencies involved.

Very early on, a parent called to say the child had been locked in the car and wasn’t breathing. But for some reason, the call-taker entered it as a child locked into a car, which is a somewhat frequent occurrence. It was misclassified. They didn’t focus on the fact that from what I’m told, the 911 caller said the child wasn’t breathing. So that’s the first mistake.

But the call-taker, within a minute, maybe 90 seconds at the most, quickly realized that the child wasn’t breathing and that takes priority, so they reclassified the call to an infant who wasn’t breathing, and they were giving CPR instructions. But for some reason, the dispatcher didn’t pick up on this.

The chronology was basically this: The first note in the computerized record says that the child was locked in the car, and then it says the child is out of the car. Once the dispatcher saw the child was out of the car and the people in the field saw it, they asked, ‘Are we in service? Can we cancel this call?’ The dispatcher said ‘Yes, you’re not needed on this call anymore.’ But what the dispatcher didn’t pick up on was that the call-taker a few feet away in the same room, maybe 20 or 30 feet away, is still on the phone with the parent giving CPR instructions. They missed that. And for the better part of eight minutes, no Fire/EMS units were sent to this address on Park Road Northwest to assist with this baby.

Interestingly enough, a police dispatcher didn’t get [confused] this way. The police dispatcher saw those notes, sent police to this address, and they ended up getting there six minutes before Fire/EMS arrived.

This is not the first 911 mistake you’ve reported on in recent years where someone died. What are some of the other cases that stand out to you? 

There have been nine deaths that I’ve uncovered where there were mistakes made at 911. We can’t say what caused those deaths, but we know that mistakes were made. There have been five this year alone. One that stands out to me is Sheila Shepperd, who on June 5, 2020 collapsed in her home with her 13-year-old daughter. Her daughter calls 911, gives her address as Oglethorpe Street, Northeast. She gets CPR instructions. This 13-year-old girl did CPR on her mother. Unfortunately, help was not on the way. It was being sent to Oglethorpe Street Northwest.

Sheila Shepperd did not survive. They tried to revive her. Fire/EMS and the hospital worked on her but didn’t revive her. The worst part is how the city handled it. Here you have a 13-year-old girl doing her best to save her mother’s life. And they immediately find out from my reporting that the Fire and EMS units were [initially] sent to the wrong address. They don’t know why. I still kept open the possibility, as a reporter, that her young daughter could have given the wrong address in her panic to try to save her mom. For five months, the city left that child hanging with no one knowing the real answer. Then a national publication called Communications Daily followed up on one of my stories and filed FOIA requests. They got the 911 call from this incident, and it showed she gave the right address. It was the call-taker that put in Northwest. It was enormously cruel that no one told this to the family all of those five months.

[OUC Director Karima Holmes issued a public apology to the family after the full information from the 911 call was published. “Their experience with our 911 system at the point of their most urgent need was not in keeping with our commitment to callers and District residents. Last summer after this incident, we conducted a full investigation of this case and the handling of this call did not meet our performance standard,” Holmes said, according to FOX 5.]

An independent audit — commissioned by the D.C. auditor and published last year — found that D.C. Office of Unified Communications had fixable problems, but it was falling short of national standards. What’s your experience of the way this office falls short?

The biggest thing is the call processing times. The other one was that they don’t use the technology to their advantage. They think the technology is going to save them. They get the latest technology, they put the money there, but they haven’t invested in the people.

No one at the 911 center goes to work thinking, ‘I’m going to make a mistake today and ruin somebody’s life.’ They’re there to do the best job possible. But they’ve even testified [before the D.C. government] saying they don’t get the training they need. The focus should have been on the people there. And that means paying them well, training them well, having good supervision, good middle management, good upper management. And a lot of that has been lacking through the years. And the audit showed some of that.

D.C. Mayor Muriel Bowser announced in February that she had reappointed Karima Holmes, who previously led OUC, to lead the agency once again. What do you make of that decision?

It shocked me that they would bring her back. It seems to be a step backward. During the time that she was away, the[audit report was published], and it covered the time that she was there. It was not a flattering report, and it talked about some leadership issues. And here they are, bringing this person back who for five years did not correct the problems. [A Bowser administration spokesperson did not respond by deadline to a request for comment on the decision to bring Holmes back. At the time of the appointment, the administration defended Holmes’ record as a leader and praised her for her past work at OUC.]

Can you explain how you came to report on this issue?

My reporting on 911 in the District of Columbia goes back to my time as a reporter. I spent 38 years in radio and TV, 25 of them in TV at Channel 9 in Washington. And [in] ancient history, a half century ago, I’d been a volunteer firefighter, cardiac rescue technician, and a dispatcher for Prince George’s County Fire. So I had an interest in this area, and I continued covering the evolution, because 911 has greatly modernized through the years.

Once OUC was created, the hope was that it would improve things greatly. Unfortunately, it didn’t live up to those expectations. I took a buyout 12 years ago from being a TV reporter, very happily. It was time to go and [I] didn’t think I would be doing reporting again. But I kept a website up that I focused on Fire and EMS called Statter 911. So I kind of kept my hand in it and I would share stories that were done by other reporters about 911 in the area and in the region and in the United States, and comment on them. And then I started, really after the Metro Tunnel incident of 2015 [where a delayed emergency response led to criticisms of both Metro and D.C.’s 911 system], to focus on OUC and problems I realized that were continuing, and went from there.

What is your process for monitoring and investigating 911 dispatches? How are you tracking these calls and these mistakes that you end up surfacing?

My intensive coverage of OUC started just before the pandemic started. I got a scanner again. I used to listen to the scanners all the time, and I got one again because I had moved to an area where I could see a lot of things going on and I wanted to know about them. And I started listening and I started to notice patterns from listening to the dispatch of D.C. Fire and EMS. You can’t listen to police in D.C. because their transmissions are encrypted, but you can very clearly hear D.C. Fire and EMS. And I started to realize that some of the things I covered as a reporter…we’re still continuing some of the same problems.

There’s a website called OpenMHz.com. And it’s really some open software that a guy named Luke Berndt had put together, which takes radio traffic from public safety agencies and puts timestamps on them. So you clearly know the chronology of events. And that probably had the biggest impact on me being able to do what I call my advocacy journalism.

It’s only part of a story, and I realize that. And that’s what the people who run D.C. 911 will tell you: I only have part of the story with the radio traffic. But it’s an important part of the story, and you can tell a lot of things from the radio traffic. You at least know what happened from the radio traffic. You may not have the answer as to why, and I’ve always searched for why from D.C. 911 and my other sources.

You’re a journalist, but you also consider yourself an advocate on this issue of DC 911. After looking into this issue for so long, what are the steps you think the city should take to improve its 911 system?

When you have a 911 center that can’t react to updates from callers, doesn’t relay crucial information, can’t cancel even though somebody called to cancel … I don’t understand how you can keep the status quo. There needs to be effective leadership that can make change, that can understand that you’ve got humans involved. There’s always going to be mistakes at 911 centers, but you can’t keep making the same mistakes. That’s what happens here. And that’s why with nine deaths, there were mistakes surrounding them. Because they keep making the same kind of mistakes. And it’s frustrating to listen to and to watch. I feel for all of these victims. I’ve stayed in touch with many of the families. They’re frustrated.