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HQCA reports on EMS response in fatal 2022 Calgary dog attack

The report outlines 5 issues HQCA found in the incident response that day and provided 16 recommendations for improvement.

Sixteen recommendations have come out of a Health Quality Council of Alberta (HQCA) report into the 2022 fatal Calgary dog attack that left an elderly woman dead.

After the June 5, 2022 incident in the Calgary community of Capitol Hill, Alberta Health Services asked the HQCA to review the incident. That report was released publicly on Thursday.

Many of the recommendations involved the way information is collected and shared both by and between Calgary 911 call takers and dispatchers and the AHS EMS call takers and dispatchers.

On June 5, 2022, a 911 caller made the initial call at 2:02 p.m. According to AHS, there were no available ambulances at 2:10 when the call was assigned to EMS under the BRAVO priority (non-life-threatening, urgent).

A bylaw officer arrived on scene by 2:10 p.m.

After attempts by both bylaw and Calgary 911 over the next 16 minutes to relay information about the patients, EMS eventually changed the event from BRAVO to DELTA (life-threatening).

At 2:28 p.m. an ambulance was assigned. At roughly the same time, the Calgary Fire Department was dispatched. CFD arrived at the scene and was directed to the back alley.  At 2:38 p.m. EMS arrives at the front door. Two minutes later, EMS assesses the patient, requests backup. The backup arrives at 2:48 p.m. and the patient was transported to the hospital.

Betty Ann Williams later died in hospital.

The owners of the three dogs involved in the attack were later charged under Calgary’s Responsible Pet Ownership Bylaw. There were no criminal negligence charges, as CPS said the incident did not meet the threshold.

Dispatch consolidation not a part of the issue: HQCA

As a part of the review, HQCA conducted 58 interviews with people connected to the incident. They also toured the two different call centres (Calgary 911 and the AHS Southern Communications Centre).

They reviewed leading practices in EMS dispatch, interviewed independent EMS dispatch experts, reviewed documents produced by both agencies and reviewed EMS data from the 14 days before and after June 5.

Five issues were raised in the HQCA report, resulting in 16 recommendations. (Summary report below.)  While some of the recommendations discussed the lack of EMS call centre staff and available ambulances, most of the recommendations involved the collection and communication of information between all of the parties.

The HCQA report clearly notes that their assessment didn’t find that EMS dispatch consolidation contributed to the outcome of the incident or the response times. It wasn’t a detailed part of their investigation, however.

AHS interim president and CEO Mauro Chies said during the Thursday media conference that communication was among the issues that day.

“It truly was a tragic event and impacted so many people, not only families but also our own staff and our partner agencies,” Chies said.

“We want to acknowledge that clearly. We deeply apologize for the role that AHS has in the delay of getting the ambulance to the scene that day.”

Charlene McBrien-Morrison, CEO of the HQCA, said there wasn’t a single factor that led to the delayed ambulance response.

“It was a series of factors, some contributing to the delay more than others, but all important to understanding what happened that day and what can improve,” she said.

When asked, McBrien-Morrison disagreed that a consolidated dispatch centre would have impacted the outcome. She said the communication protocols were in place, they just weren’t used correctly.  She said that to assume just because people were in the same room sitting together that it would have solved this, wasn’t something they considered appropriate. These are busy places dealing with intense call volumes, she said.

“In our report, you’ll see reference to the premise that a ‘twist and shout’ would have fixed things,” she said.

“No. That is not something you would want to base a best practice around delivering emergency services. You want very hard and fast communication avenues that should be utilized.”

Calgary 911 responds to recommendations

Glenda Sahlen, Deputy Chief for Calgary 911, said that there’s much to learn from the recommendations provided by the HQCA report. 

With that said, Sahlen said the provincial decision to take over medical dispatch has created “additional complexities.” She agreed that a 911 call centre is a busy place. This could have been a so-called twist-and-shout situation.

“However, that does not mean that there’s no opportunity there to turn to your co-worker and say, ‘this is bad. We need an ambulance there right away,’” Sahlen said.

Calgary 911 welcomes the recommendation to co-evaluate calls. Sahlen said in the past AHS hasn’t always been available to accommodate requests for co-evaluation of calls.

Sahlen said they would be speculating on a potential change in Ms. Williams’ outcome with the co-location of dispatchers.

“I can say that communication would have been better if we had medical call takers in our centre,” she said.

The review also showed that tension exists between Calgary 911 and AHS EMS dispatch because of the consolidation. It was identified as an issue in this incident.  

AHS CEO Chies said that it’s going to take time and conversation to work through that issue. Generally speaking, he said the sides work well together.

“We have to look at our processes where we find differences between the organizations but are fully committed to making sure that we can eliminate those in the best interests of our services,” he said.

Lack of call centre staff, ambulances

The review outlined resource issues, both in the EMS call centre and in available ambulances.

At that time, Calgary was in a Red Alert situation, meaning no ambulances could respond. The call, because it was initially coded a Bravo response, was put into a pending queue.

AHS showed that compared to the 14 days prior and after June 5, this day was an outlier in terms of high-priority calls.  

Calls to the EMS call centre to provide updates on the patient’s condition were attempted a number of times. They had difficulty getting through to the call centre via the 911 call taker. The report showed the call centre was short-staffed. They were short six people, and at the time one person was on a break.

Under the prior dispatch system, the on-scene personnel could have been directly connected with EMS dispatch to provide information, instead of going through a 911 call taker who had to connect with EMS dispatch.

AHS said they’re working to fill the gaps in personnel and in available ambulances.