A “confluence of many things” led to the slow response of EMS to June’s fatal dog attack in Calgary, a review by the Health Quality Council of Alberta said Thursday.
“There was no single action or activity that by itself slowed the ambulance response times,” HQCA CEO Charlene McBrien-Morrison said Thursday afternoon.
The HQCA report made 16 recommendations to address five areas: the call’s initial priority level, communicating updates on the patient’s condition, availability of EMS, the exact location of the incident, and interoperability between Calgary 911 and AHS EMS.
A mix up of communication protocols, patient evaluation protocols and dispatch protocols caused a delay of an ambulance to arrive at the scene, potentially 20 minutes after it could have been there.
But the report said the consolidation of the province’s emergency dispatch system did not slow the response.
“Communication protocols were in place, they just weren’t used correctly,” McBrien-Morrison said of the apparent communication breakdown between EMS and Calgary 911. “And the tools that were there were either misunderstood or misused.”
An independent, comprehensive review of the incident, including dozens of interviews, revealed it took an hour to get Betty Ann Williams to hospital after the call first came in.
Dr. Ian Walker, the Alberta Health Services EMS medical director, said he doesn’t know whether 86-year-old Betty Ann Williams’ outcome could have changed, after he reviewed the incident.
“I don’t think that’s an answerable question,” Walker said.
“I don’t think that’s a knowable piece of information – it’s speculative.”
Walker acknowledged that earlier responses for trauma patients produce better outcomes.
When the call initially came in, it was assigned to police and was given a lower priority level because it was originally identified as a dog bite.
A bylaw officer arrived shortly after and contacted CPS dispatch to get an ambulance. Another “high-intensity” CPS incident occupied the CPS radio frequencies and the bylaw officer had a hard time getting through to dispatch.
Short staffing at the EMS call centre delayed a response to the Calgary 911 operator and bylaw officer. Of the 19 EMS operators scheduled that day, six were absent and another was on a scheduled break when the call came in.
And EMS was already on red alert at the time — no ambulances were immediately available. The investigation showed EMS was under extraordinarily high demand that weekend and the number of ambulances were low compared to two weeks before and after the incident.
The report said if the call been given the priority of a life-threatening call, an ambulance would have been dispatched as soon as possible.
An ambulance arrived 10 minutes after it was eventually dispatched,but was sent to the front door, not the back alley where the incident was taking place.
The HQCA CEO said the EMS response was more than 30 minutes after it was dispatched, but based on modelling, it would have been about 14-and-a-half minutes if the initial incident was coded correctly.
AHS working on fixes
AHS said it accepted the findings of the report and is already working on the recommendations that affect its operations, and the provincial health authority is working to develop a memorandum of understanding with the City of Calgary to address other recommendations.
“Betty’s death was a tragedy, a very sad tragedy,” AHS official administrator Dr. John Cowell said. “This was an uncommon emergency.”
Cowell acknowledged EMS response is part of his mandate since being named to the position in November 2022.
“We accept our role having to do with emergency response times that don’t meet targets.”
In addition to addressing items in the report, AHS interim CEO Mauro Chies said EMS is also working on implementing a real-time tool to share expected service times with those who call 911.
“Our commitment is to improving and ensuring that these same factors do not contribute to another tragedy,” Chies said. “Loss of life cannot be prepared for, but our actions will honour Betty Ann Williams and we hope that we can repair trust in EMS.”
The Calgary Police Service said it is reviewing its response to EMS-related events, in light of Williams’ death.
One recommendation for police was the use of a shortlist of questions to provide information to dispatchers, known as the Secondary Emergency Notification of Dispatch (SEND) protocol.
The report said the information given to EMS was taken in a way that “didn’t follow an established process or call standard,” referring to SEND.
“In February 2021, we trained our members on the SEND protocol,” CPS said in a statement.
Call transcripts between Calgary 911 and AHS EMS call centre show four calls were made about Williams’ condition in an effort to have an ambulance dispatched.
On the second call at 2:23 p.m., the EMS operator asked about Williams’ condition, including whether she was alert or if there was any serious bleeding, but admitted there were no ambulances assigned.
The Calgary 911 operator said officers on the scene needed EMS “hot” – another term for immediately.
The fourth call, made at 2:29 p.m., revealed the call had been assigned a higher priority and crews were “about seven minutes out.”
“It could have been a twist and shout situation where the fire call taker or the police call taker is sitting close to the medical call taker or medical dispatcher and just said: ‘This is bad,’” Calgary 911 deputy chief Glenda Sahlen said.
The AQHC CEO said the ‘twist and shout’ method is not an established best practice in emergency response.
Having call centres talk to each other
The report noted the EMS dispatcher did not speak directly with the person who originally called 911 and instead the Calgary 911 operator passed along information to EMS. The HQCA recommended more co-evaluation, when operators from EMS and 911 simultaneously ask questions of the caller to evaluate the situation.
Calgary 911 said that work has already been done.
“Calgary 911 wrote the co-evaluation policy in January of 2020, and it has been shared and accepted by the other four major municipalities and has become part of the Alberta 911 standards that we are accountable to for 2023,” Sahlen said. “The opportunity and need for medical evaluation did not happen in this case, which is something we will address.”
The report also highlighted inter-operability challenges between Calgary 911 and EMS systems, and a tense relationship following provincial consolidation of EMS dispatch.
“It is cultural. And after the consolidation occurred in January of 2021, we have some relationships to rebuild and some work to do,” Sahlen said.
Sahlen said Calgary 911 has asked for the ability to have a picture of availability of ambulances, something AHS has yet to provide.
Lorian Hardcastle, associate professor in law and medicine at the University of Calgary, said this report mirrors the concerns Albertans have had about EMS response times.
“This report really affirms that those are legitimate concerns and that some of the pressures that we’re seeing in the system are leading people, in some cases, to slip through the cracks,” Hardcastle said.
“The solutions offered were multifaceted, so there’s a number of different policy changes that can be made in order to improve response times.
“This dovetails well with the work that is already ongoing within Alberta Health Services to improve EMS issues.”
Earlier in the week, AHS announced it would add 20 more ambulances in Calgary in the coming year, on top of the same number added in the past year.
But Hardcastle said the interactions of multiple agencies – Calgary 911, police, bylaw and EMS – provides unique challenges and opportunities.
“We know from the health-care context, that whenever people are handed over from one health professional to another — for example, at a shift change — that’s an opportune time for errors and miscommunications that affect patient care to happen,” she said.
“At the same time, when there’s multiple different entities involved that come to it with different perspectives, they can also sometimes help one another, see different potential solutions or can act as redundancies in the system.”