An official report found the wrong priority level was assigned during a 911 call after a fatal dog attack on a Calgary senior last year that led to a longer response time..Betty Ann Williams, 86, died after she was attacked by several dogs in the alleyway behind her home in the 1500 block of 21 Avenue N.W. on June 5, 2022..Williams died from her injuries while on the way to hospital..The Health Quality Council of Alberta (HQCA) and Alberta Health Services (AHS) released the document on Thursday and said, "This was a difficult event for all involved."."People set out to do the right thing and yet there were times when the system was not operating at its best," Chief Executive Officer of the Health Quality Council of Alberta Charlene McBrien-Morrison said.."Our work was to understand and identify the system issues and contributing factors involved in each aspect of the event. On the surface, this might seem a simple event to review; but in fact, emergency response is a complex system involving several organizations, teams, individuals, processes, policies, norms, tools, and equipment.".McBrien-Morrison said the report looked at the actions of individuals only in the context of understanding how all these factors affect how people work within that system.."We learned there was no single action or activity that by itself slowed the ambulance response time that day," McBrien-Morrison said..The 157-page report said it was a series of factors, each contributing to the delay in EMS response.."Some more significant than others, but all important to understanding and addressing opportunities to improve," McBrien-Morrison said..The EMS response time for the dog attack was 30 minutes and 22 seconds. That's calculated from the time the EMS call taker entered the event into the CAD terminal until the first EMS unit arrived on scene. From when the 911 call was made, EMS arrived 36 minutes and nine seconds later..The response time for the event from the time it was updated to a delta event to arrival on scene was 11 minutes and 11 seconds..Five issues were identified that contributed to the prolonged EMS response time. For each issue, contributing factors were identified..The HQCA report highlighted several challenges that contributed to the response on June 5, including:.No available ambulances in the Calgary Zone for calls deemed to be lower priority.A high number of high-priority EMS dispatch events at the time of the incident, and paramedic crews busy with patients in Calgary emergency departments.Issues with the assessment and level of priority that was initially assigned to the incident by EMS dispatch.A shortage of staff in the EMS Southern Communications Centre on the day of the incident.Communication issues between EMS and City of Calgary emergency dispatch systems. Note that the consolidation of dispatch was not found to have contributed to the outcome of this incident nor to response times..One of the main issues was the initial information given by the 911 police call taker was “we have an approximately 83-year-old female that was attacked by three dogs and she has a bite injury to the head.” .Following the established standard operating procedure for this type of event the EMS call taker used a manual card set to assign a priority level. A bravo priority level (serious but not life threatening) determinant labelled as 03B01 (event involves an animal bite or attack involving a possibly dangerous body area) was assigned..Calls assigned this determinant are automatically given a yellow priority response (non-urgent — not serious or life threatening).."We have thoroughly reviewed the Health Quality Council of Alberta’s (HQCA) assessment and report regarding the June 2022 fatal dog attack that resulted in the death of an 86-year-old woman," the Calgary police said in a release..The HQCA report provided recommendations to the CPS around using the Secondary Emergency Notification of Dispatch (SEND) protocol and moving towards a provincial law enforcement response plan for Emergency Medical Services (EMS)-related events.."In February 2021, we trained our members on the SEND protocol. SEND is a shortlist of questions used by authorized emergency service personnel calling from the field to streamline the provision of essential information needed by dispatchers," said police.."We are currently undergoing a review of our response to EMS-related events. We are also taking steps to move toward the provincial law enforcement response plan by working with Alberta Health Services and Calgary 911.".There were no charges laid against the owner of the dog.."In October 2022, we publicly provided the results of our criminal investigation," the CPS said.."Through our findings and in consultation with the Crown prosecutor, it was determined the necessary elements to support laying charges for criminal negligence causing death against the owners of the dogs, were not met in relation to this incident.".The report found that EMS was in a “Red Alert” at the time of the incident as demand exceeded available resources..According to the report, the Southern Communications Centre was short staffed, only 31 of 38 ambulances in the Calgary area were staffed, and another 20 events were waiting for an ambulance to become available..“This is very tragic and my heart goes out to the family for the loss of their loved one. It didn’t have to be this way,” NDP Health Critic David Shepherd said..“For months, we have heard warnings about chronic understaffing of emergency services and the potentially dangerous outcomes of the chaos the UCP has created in our health care system."
