Critical flaws in Florida's 911 system
By Zac Anderson
Published: Saturday, January 17, 2009 at 1:00 a.m. Last Modified: Saturday, January 17, 2009 at 2:59 p.m.
First of three parts
Moving ceremony for Denise Lee
Harold Muxlow 911 call Audio
Sabrina Muxlow 911 call Audio
Jane Kowalski 911 call Audio
Dispatchers get 911 call from Denise Amber Lee Audio
Lee's father speaks in Tallahassee Audio
One year after Denise Lee's murder Video
911 caller tells police about hearing Denise Amber Lee's screams Video
Every year, Florida 911 workers make hundreds of critical errors that endanger lives and leave people waiting for help, a Herald-Tribune investigation has found.
Records show that Florida’s 911 call takers and dispatchers — the vital link between emergency responders and distressed callers — send help to the wrong address or neglect to send any help at all.
They fall asleep on the job and abandon their posts to run errands. They argue with heart attack victims and hang up on hysterical callers.
In the most egregious cases, 911 workers listen to callers’ pleas for help and simply decide not to send a police officer or ambulance.
Despite chronic errors and even deaths, state officials and many local agencies have done little to stop the mistakes.
Florida’s 911 centers have no uniform standards and little oversight. Unlike at least 32 other states, Florida does not mandate training or certification for dispatchers. In some cases, the Herald-Tribune found, dispatchers have been allowed to start processing calls just two days after being hired.
And the mistakes are piling up.
The newspaper spent six months gathering and analyzing five years’ worth of discipline reports and complaints against 911 centers across the state. The paper reviewed more than 1,000 cases from more than half of Florida’s 67 counties. It also interviewed more than 50 current and former 911 workers, supervisors, policymakers and victims of 911 mishaps.
Although the vast majority of calls are handled correctly, the newspaper found that mistakes occur every day and that government officials have neglected the 911 system, allowing it to lag years behind police, firefighters and paramedics in training and other standards.
Among the findings:
--Each year in Florida, hundreds of 911 dispatchers violate protocols designed to ensure swift and accurate emergency response, complaint documents show. More than a third of those mistakes delay the arrival of police, fire or medical responders, threatening lives.
--Hundreds more 911 employees demonstrate gross unprofessionalism with actions that include sleeping on the job, not showing up for work, leaving stations unattended or turning off emergency alert tones so that they will not be disturbed.
--Dozens of errors put emergency responders in jeopardy when dispatchers failed to fully describe a dangerous situation or update criminal databases. A Gainesville police officer faced a suspected killer during a traffic stop on Sept. 14, 2006, but did not know because of a dispatcher’s error, records show.
--Heavy turnover and training standards that vary widely from one community to the next virtually ensure mistakes will be made by overworked, ill-prepared phone and radio operators. Even so, top law enforcement officials lobby against more training because of concerns about money.
--Most 911 centers have adopted standards that draw on accepted industry practices. But no minimum standards are required by Florida law. In addition, Florida officials do not require 911 centers to track mistakes or determine if errors were fatal.
--Even when mistakes are discovered, 911 administrators often dole out light punishment, allowing operators to rack up multiple mistakes without serious consequences. A Bradenton dispatcher was reprimanded for 9 offenses during her first 11 months on the job. Three times she sent rescue workers to the wrong address on “serious calls,” and once she failed to alert police about a missing 4-year-old.
Julie Righter, a national expert on 911 standards who runs a center in Nebraska, said 911 workers have an extremely tough job and handle most calls without incident.
They perform thankless work for little pay, yet are a key cog in a system that saves lives. But Righter also said that the competence of a 911 operator should not be a factor in whether someone lives or dies. And many 911 centers have a long way to go before the proper standards are in place to ensure there is little chance “you’ll have an error when someone’s life is on the line,” she said.
Raising standards has been difficult. The two main voices of law enforcement in Florida — the Florida Police Chief’s Association and the Florida Sheriff’s Association — have opposed increased requirements because of the expense.
In the absence of statewide standards, the 911 system has continued to tolerate mistake after mistake.
Widespread problems
Every so often, a tragic error by a 911 dispatcher captures headlines because someone dies.
A year ago today, a mishandled call to Charlotte County’s 911 center robbed law enforcement officers of a critical opportunity to save 21-year-old Denise Lee.
A concerned driver heard someone screaming in the back of a Camaro on U.S. 41 and called 911. The caller was so concerned she stayed on the phone for nine minutes, following the car to give street-by-street locations.
Although 911 workers suspected that the passenger might be Lee, dispatchers failed to send help.
Several deputies were just minutes away.
The young North Port mother was found two days later, buried in a shallow grave with a single gunshot wound.
Blame was passed around. The radio operators blamed the 911 call taker for shouting across the room instead of calmly sending a computer message. The Sheriff’s Office defended the call taker and disciplined the radio dispatchers for not taking action.
It was a communication breakdown that shook the community’s faith in the 911 system.
A year before Lee’s death, another death was attributed to inaction by 911 employees, this time in Pasco County. For seven minutes, 911 supervisor David Cook refused to offer lifesaving advice to a caller whose girlfriend was choking and near death. The supervisor did not want to get on the phone with a “hysterical caller,” according to reports in the St. Petersburg Times. Co-workers later reported that when Cook learned the woman had died, he joked, “She must have bitten off more than she can chew.”
More recently, inaction by dispatchers was partly blamed for the death of a Plantation woman who dialed 911 while driving to the police station.
For three minutes she begged for help as a man with a gun chased her down the street. She described where she was and told the 911 operator she was driving to the police station. But when she arrived, no officers had been sent to protect her.
The man shot Olidia Kerr Day to death, then killed himself.
Many of the officials who run the state’s 250-plus 911 centers argue that these sensational episodes are the result of isolated and rare human errors.
But the Herald-Tribune found hundreds of mishandled calls that might have contributed to someone’s death if not for one thing — luck.
--In Escambia County, a new 911 call taker sent ambulances to the wrong address three times in a four-month span. She delayed help for an unconscious person, car accident victims and a person having a seizure. In the car accident case, the caller gave the location as North Z Street and repeated “Z, like zebra,” records show. The dispatcher entered North C Street.
--At least twice in the past five years in Pinellas County, ambulance drivers arrived on the scene to find their patients holding a gun. The 911 workers failed to warn the paramedics, according to a complaint log.
--In Sarasota County, a woman called 911 from the Chili’s restaurant in Venice to report an unconscious person and clearly stated the address. The dispatcher sent paramedics to a Chili’s in Sarasota.
--In Hardee County, a 911 worker walked out of the call center, leaving it empty with no one to answer the phone for eight minutes while she looked for a co-worker. Another worker failed to report an escaped prisoner who had jumped out of a window at a nearby county courthouse. Five days later, the same woman sent paramedics to the wrong address for a heart attack, delaying help by 27 minutes, records show.
The Herald-Tribune found more than 600 similar mistakes statewide in the past five years. The actual number is likely measured in thousands. The Herald-Tribune was only able to review complaints and discipline reports from about 40 of the state’s more than 250 centers that directly or indirectly handle 911 calls.
Several dozen agencies contacted by the newspaper did not comply with Florida public records law, failing to respond to written and e-mailed public records requests. Other centers reported no problems or just a handful, even though 911 experts say errors occur in most centers practically every day.
Why mistakes happen
There is a reason so many 911 workers — nearly 75 percent for some agencies — leave within the first year.
They are asked to field life-or-death calls under extreme stress for less than $30,000 a year.
In a matter of seconds, they must ask the right questions to understand an emergency, assign a priority to the call and pass on the correct information to responders.
The large number of non-emergencies, nearly half of all calls for some agencies, can create a “boy who cried wolf” phenomenon, in which workers take real emergencies less seriously because they have dealt with so many minor issues.
Add it all up and the potential for errors — misunderstanding an address, pushing the wrong key on a computer keyboard, getting distracted — is high.
That is why the best dispatch centers establish excruciatingly detailed protocols for answering 911 calls and require months of intense training. They make sure seemingly small errors do not go unmentioned and hold people to high standards.
But in Florida, the 911 agencies have been left largely on their own, with no statewide requirements for training, staffing or quality control, little oversight and paltry state funding.
As a result, training and monitoring vary widely.
In Bradenton, new 911 dispatchers have 14 weeks to master everything and begin working on their own. They learn on the job with no classroom training. In Broward County, new hires spend 12 weeks confined to a classroom and the training program lasts a full year.
The lack of standards is a problem nationwide, said Nancy Pollock, a 911 consultant who ran centers in Minnesota.
“Unfortunately the only way this is going to change is if the highest government in an area takes ownership of this, and in most cases that’s the state,” she said.
In the absence of a state standard, several national accreditation programs lay out best practices.
Yet because the state does not push accreditation, only 15 of Florida’s 911 centers, among them Sarasota County’s, have qualified.
Ignoring the problem
Many of the county governments, sheriff’s offices and municipalities that oversee 911 centers do little to track life-threatening mistakes.
The state of New York requires every 911 center to track complaints.
But only a few of the Florida centers contacted by the Herald-Tribune could provide copies of a complaint log, or a list of every disciplinary action taken against 911 employees. For many, the only way to review 911 errors is to pull dozens of individual personnel files, and sift through thousands of pages looking for discipline reports.
Even that will not catch all of the mistakes because documents describing errors are not always retained.
As a result, many 911 centers operate with no way of knowing how many errors are made, who is making them and how to reduce errors.
In Escambia County, 911 manager Bob Boschen said he began keeping a complaint log after the Herald-Tribune contacted him to request complaint documents last year.
Boschen said he realized that tracking problems is part of providing “the best customer service.” His goal now is to have less than two valid complaints a month.
Some Florida 911 agencies, including Escambia, systematically seek out mistakes in regular audits of every dispatcher.
In Sarasota County, dispatch managers randomly review 10 law enforcement calls each week and 3 percent of medical calls each month to make sure employees verified addresses, classified emergencies properly and asked the right questions.
The checks expose where employees need training and discourage complacency, said Sarasota sheriff’s Capt. Jeff Bell, who runs the 911 center.
“It’s a little scary because you’re really opening yourself for criticism,” said Pollock, the consultant. “But a smart manager views complaints as a good thing. If you have something wrong you want to know about it before something really tragic happens.”
Yet while some agencies have documented more than 100 problems in their 911 centers over the past five years through complaint tracking, the Herald-Tribune found four agencies that recorded no problems at all. Others had very few.
The Bradenton Police Department — an agency with 15 dispatchers — had 20 discipline cases, while Charlotte County, with more than twice as many dispatchers, had just 10.
A former Charlotte County 911 worker told the Herald Tribune that she witnessed problems in the center that went undocumented.
Amy Corbett, who worked in Charlotte County’s 911 center for four months in 2006 and left for personal reasons, said most of the people in the 911 center were competent professionals, but she remembered an incident where a call taker was sleeping on the job and the other workers just laughed and threw candy at her.
“I didn’t see them handle mistakes that happened,” Corbett said. “Some were swept under the carpet, or you’d just have a supervisor talk to you, but it was never anything that was formal.”
Charlotte County Sheriff’s Office Capt. Sherman Robinson said his office has no record that Corbett reported the problems she saw in the 911 center. Robinson said that if a problem was brought to their attention they would have taken action.
Charlotte does not keep a complaint log. Officials say their informal system works because they get few complaints, and discipline is adequate.
“I can’t tell you the last time I got a complaint,” Robinson said. “I think we hold people to a pretty good standard.
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Few consequences
Beyond training and monitoring, some experts say dispatch mistakes in Florida have been increased by lax punishment when errors are discovered.
In some cases, even when a mistake ends in tragedy, the punishment is light.
The two dispatchers who did not send deputies to investigate the 911 call shortly before Lee’s death were each suspended but stayed on the job. It was the first time in five years that Charlotte County had suspended a dispatcher, a common punishment elsewhere. Then-Sheriff John Davenport said they were good employees who just slipped up.
The Herald-Tribune’s investigation found that punishment levels vary widely from one place to the next.
In Alachua County, where the 911 center has been held up as a model of excellence, employees are twice as likely to be suspended as 911 workers statewide, the Herald-Tribune’s analysis shows.
But in many 911 centers, managers tolerate repeated mistakes.One Manatee County dispatcher delayed emergency workers six times during her first year on the job, including not sending an ambulance to a motorcycle accident. She was suspended for one day.
Other Manatee dispatchers have similar track records. One was late for work fives times in a year and received a day’s suspension. Another was disciplined five times in a year — for insubordination, attendance problems and an ambulance delay — without receiving more than a letter of counseling.
In April 2008, 17-year-old Braden River High School senior Bre Doran’s boyfriend flipped his truck near State Road 64 in Manatee County. Doran passed out when her head shattered the windshield. When she woke up, Doran could not move her neck.
“It hurt so bad,” she said.
A passing driver called 911.
At the Manatee County 911 center, Mary Ellen Holloway took the call. She made a computer mistake and the information was never forwarded to a radio dispatcher responsible for sending an ambulance.
Doran waited 91 minutes before the error was discovered and an ambulance arrived.
It was not Holloway’s first mistake.
Four months earlier, in December 2007, Holloway committed the same computer error and failed to send help to a woman complaining of abdominal pain.
The error that left Doran stranded was Holloway’s fourth discipline episode in seven months. She received a warning and remedial training.
Holloway said the experience with Doran’s truck rollover shook her. She has not had an error since.
“The county takes very seriously issues like that, and I know for myself it was scary for me,” Holloway said.
Bill Hutchison, Manatee County’s public safety director, said he believes the agency has a balanced approach to discipline. The best thing for the public is often to retrain employees, not fire them, he said.
The Herald-Tribune analysis found that punishments statewide rarely end a dispatcher’s career. Only 2 percent of the complaints ended in termination and only 18 percent involved a demotion, loss of job or a suspension.
Most people escape with a warning, even after repeat mistakes involving high priority calls: those involving medical emergencies or imminent threat.
The Herald-Tribune found more than 25 people who kept their job even after being disciplined four times and nearly 200 employees who were disciplined at least twice.
Escambia County 911 dispatcher John “Jason” Dunn had 10 discipline episodes between 2004 and 2007, the most for his agency.
Dunn had five documented ambulance delays in three years, including one episode where he came into work groggy after staying up for 24 hours and sent paramedics to the wrong nursing home for a patient with “chest pains and in severe respiratory distress.”
In an interview last week, Dunn noted that he has not had an error in more than a year.
“Five delays, that sounds like a lot, right?” he said. “I know it seems bad, but you have to consider the total volume of calls, the hundreds of thousands of calls I handled perfectly. It’s tough because every call is important. It’s a job where you want 100 percent accuracy, but that’s impossible.”
Staff writer Chris Davis contributed to this report.
http://www.heraldtribune.com/article/20090117/ARTICLE/901170311
