Emergency Disservice: Inside DC’s Dysfunctional 911 System

One evening in mid-May, a fire broke out in the bedroom of a DC apartment.

A man who lived there dialed 911. On the other end of the line, a dispatcher with the District’s Office of Unified Communications—which handles the city’s emergency calls—directed fire engines to a building at 1704 R Street, Northwest, near Dupont Circle.

When firefighters arrived, they realized something was amiss. They smelled no smoke. They heard no alarm bells. There was no fire.

Meanwhile, flames were tearing through a fourth-story apartment across town near Anacostia High School. The address? 1704 R Street, Southeast. Same street, same number, different quadrant of the city. The dispatcher had made the sort of error you might expect of a tourist getting lost on the way to a restaurant—but not from the city agency responsible for ensuring that police, firefighters, and medical workers get where they’re desperately needed, and quickly.

The family of six who lived in the apartment were lucky. While a fire in a previous building at the same address had killed two people in 2013, the current building was relatively new, and its sprinkler system saved them and their two dogs from physical harm. Still, their unit was severely damaged by the time help arrived. “If they would have come earlier and came to the right address,” the apartment resident who called 911 later told WUSA, “I believe it wouldn’t have even gotten this bad.”

This wasn’t OUC’s first botched 911 call. Five years ago, a dispatcher took four minutes to send firefighters to a fire in a rooming house on Kennedy Street, Northwest—quadruple the national standard of 60 seconds. A man and a nine-year-old boy were killed in the blaze. In 2020, a 13-year-old girl called 911 after her mother suffered a heart attack. Paramedics were sent to an address on Oglethorpe Street, Northwest, instead of Northeast and arrived nearly 20 minutes late. The woman later died in the hospital. Two years ago, dispatchers confused Savannah Street with Savannah Terrace, Southeast, and first responders arrived ten minutes late to the home of a two-day-old baby who had stopped breathing. The infant was pronounced dead on arrival at Children’s Hospital. Just last week, an OUC computer outage—the fifth since May—contributed to a 15-minute delay in getting appropriate care to a five-month-old infant surfing cardiac arrest. The child died. City officials said the matter was under investigation.

In each case, there’s no guarantee that a faster response would have saved lives—but in dire situations, every second counts. “It doesn’t matter how good we are at putting out fires or saving lives,” a fire-department official tells Washingtonian. “If we can’t get to the patient in time, it doesn’t do any good.”

Emergency dispatch is difficult work, an exercise in coordinating chaos. Mistakes happen. In DC, however, the frequency and severity of those mistakes reflect what some inside and outside city government see as a dysfunctional system. In recent years, the District’s 911 response has been hampered by dropped calls, dispatch errors, and long response times that fall short of national standards—and have led to accusations that the system failed to prevent avoidable deaths.

Mayor Muriel Bowser has consistently defended OUC’s performance and leadership. But the city’s auditor has criticized the agency for failing to acknowledge its mistakes. A former OUC head is suing the mayor and the city, accusing the agency of mismanagement and retaliation. More than 100 neighborhood leaders from across DC have called for an independent review of OUC’s shortcomings.

Meanwhile, DC Fire and EMS has taken matters into its own hands, creating a shadow dispatch operation for fire and medical emergencies that spends much of its time mopping up OUC messes in real time. DC Council member Brianne Nadeau, a frequent critic of the agency, finds that telling—and alarming.

“Is it not wild to you that our first-responder agency has set up a workaround for our 911 call center?” she says. “It’s bonkers.”

The Gadfly

Sitting in a leather recliner, Dave Statter opens his laptop. A retired reporter who spent decades working for WTOP and WUSA, Statter was once a volunteer firefighter and dispatcher in Prince George’s County. He now lives in Pentagon City, where from an apartment high above I-395 he continues to monitor the city.

Two scanners fizz with emergency-response information. “I’ve been listening to radios like this since I was 13,” Statter says. He pulls up a website, OpenMHZ.com, that collects radio traffic for police and fire departments around the country. Statter plays a series of recordings in which a dispatcher with DC’s OUC attempts to help a sick person at a McDonald’s on Pennsylvania Avenue in Southeast.

“I want you to think about this address,” Statter says, referring to the location given by the dispatcher to first responders. “McDonald’s, 1539 Pennsylvania Avenue, Northwest. Where would that be?”

Between the White House and Lafayette Square?

“Exactly,” he says. “There’s no McDonald’s on that block!”

What follows is something out of the Keystone Cops. Responders spend nearly 20 minutes arranging to meet Secret Service personnel at a nearby McDonald’s on 17th Street, Northwest—just in case the problem is actually there—before someone in the field redirects them to the correct location, roughly four miles across town.

“There are always going to be mistakes with 911,” Statter says. “But what is frustrating to me is the constant repetitive nature of these mistakes.”

Though handling a 911 call may seem straightforward, there are actually five steps from the time a caller dials in to the moment help arrives on the scene. Each step builds on the last, and errors can cascade. First is the wait time before a call taker picks up the phone—this should be less than 15 seconds, but when things go wrong, it can last several minutes. Next comes call processing, when a call taker gathers information and decides how to categorize, or “code,” the request for help. This is often when addresses and other critical information are flubbed. The third step is call-to-dispatch: Coded calls are sent to dispatchers, who decide which response units to send based on urgency, need, and the availability of nearby police, fire, and EMS workers. After that, there’s the wait time between dispatch announcements and units being en route, plus the time it takes those units to reach their destinations.

DC has long struggled with this process. During his 1999 inaugural address, Mayor Anthony Williams promised that his new administration would get 911 calls answered. Four years later, three different callers attempting to report a house fire in Dupont Circle heard recorded answers and then gave up. The fire killed a 24-year-old man, and frustration with the city’s 911 response reached critical mass.

Enter the OUC. Given control of the city’s 911 call taking and responses in 2004, the agency consolidated duties previously spread between police and fire operators under a single, high-tech roof, the better to reduce delays and miscommunication. Early results were encouraging. That fall, the city claimed that operators answered 94 percent of calls within five seconds, up from 64.5 percent the previous year—and over the same period, calls that hung up without being answered fell from 10 percent to 3 percent.

But the honeymoon didn’t last. By 2008, firefighters were complaining to Washington City Paper about dispatchers telling them “S as in celery” when they were sent to S Street and “Q as in cucumber” when sent to Q Street. In 2015, call processing delayed firefighter response to a Metro fire. A passenger died in a smoke-filled train car. The same year, OUC responded to a call about a choking toddler by sending a paramedic unit located roughly a mile from the boy’s home, even though another unit was just blocks away. The boy died. During a subsequent DC Council hearing, then–OUC director Jennifer Greene said that the national call-to-dispatch standard of 90 seconds wasn’t “realistic” for her agency, which was averaging between 120 and 130 seconds. She resigned shortly thereafter.

Statter began focusing on OUC around that time. As he listened to his scanners, he says, patterns emerged—dropped calls, duplicate dispatches, address blunders. On his X account, Statter compiled and called out the agency’s failures. Today, he might be OUC’s most prominent public gadfly. His website features headlines such as
“Mother & baby trapped, DC911 sends firefighters to the wrong address” and “Family wants answers a year after DC911 sent help to the wrong location.”

Statter also keeps a list of more than a dozen cases in which OUC made a mistake and someone died. “We’re not saying that 911 caused the deaths,” Statter says. “You can’t prove that. But we know during these deaths, at the time people called 911, there were mistakes or delays.”

Comparing DC’s 911 performance with other cities is complicated. The more than 6,000 911 centers nationwide are managed by a patchwork of municipalities, counties, and public-safety enforcement agencies, and no national performance database exists. “911 is a local entity,” says April Heinze, chief of 911 operations for the National Emergency Number Association. “It’s very difficult to have precisely the same manner of doing things all the way across the country.”

Emergency-response problems aren’t unique to DC. In New York City, the union representing dispatchers has complained about understaffing. In Austin, people have struggled to have their 911 calls answered; an audit this year found that many call taker positions were unfilled. In June, a cybersecurity glitch caused a massive outage of Massachusetts’s state 911 system for two hours.

DC also deals with one of the country’s heaviest 911 call volumes. Last year, OUC handled about 1.77 million calls—twice what the equivalent call center in Seattle, a larger city, handled in the same time frame.

In October 2021, the Office of the District of Columbia Auditor released a scathing review of OUC, determining that the agency was slower to answer 911 calls and send help than required by national standards. “We basically found a dysfunctional agency, all across the board,” says city auditor Kathleen Patterson. “Lack of staff, lack of training, lack of use of technology, insufficient supervision, insufficient oversight of the chain of command. It might be easier to say what we didn’t find.”

Patterson’s review of DC’s 911 system made 31 recommendations for improvement. OUC claims it has completed 27 of them. Problems remain. Public-safety standards established by the National Emergency Number Association stipulate that 90 percent of incoming 911 calls should be answered within 15 seconds. Between March 1 and June 30 this year, OUC reports, it reached that standard on just 18 days—and on its worst day, June 9, the agency answered only 37.4 percent of calls within 15 seconds.

Last September, more than 100 current and former Advisory Neighborhood Commission members called for an independent task force to examine and address “chronic and systemic problems at OUC.” In July, Nadeau wrote a letter to OUC director Heather McGaffin accusing the agency of being “derelict in providing transparency, claiming that “on numerous occasions, when my staff reaches out, the agency does not provide information or even a response.”

McGaffin and OUC spokespeople did not respond to multiple Washingtonian interview requests. Nor did Mayor Muriel Bowser. A spokesperson for deputy mayor for public safety and justice Lindsey Appiah, who oversees 911, acknowledged a request but then stopped responding. (After this article went to press for Washingtonian’s print edition, another spokesperson from the mayor’s office contacted the magazine to propose an interview with Appiah about crime being down in DC. Asked whether Appiah could instead discuss OUC, the spokesperson asked for more information, then never followed up.)

At a DC Council hearing in February, McGaffin defended her agency’s performance—acknowledging that while there are “issues” with the city’s emergency dispatch that “we’re trying to fix,” those are “far outweighed by the positive outcomes that we have.” Bowser has previously defended OUC, too, pointing out the stress that its call takers and dispatchers are under. She also has singled out Statter’s criticism, arguing that he would find similar problems with neighboring jurisdictions if he scrutinized them.

“I listen to the radios pretty frequently from multiple jurisdictions in the area,” Statter says. “And I don’t see the frequency of mistakes and the repeated mistakes of OUC.”

The Outsider

From the start, Cleo Subido was an outsider. A native of the other Washington—the land of Twin Peaks and the Space Needle—she spent nearly three decades as an emergency dispatcher, supervisor, and trainer in the Seattle area before moving to DC in 2020 to work for OUC training dispatchers.

In December of that year, then–OUC director Karima Holmes announced her resignation. Patterson’s audit was underway, and the agency was under fire. Subido was named interim director. She soon came to understand why things were so bad. Later, she would file a lawsuit accusing the city and agency of hiding and downplaying mismanagement and mistakes.

At OUC’s call center, a sprawling office building on the St. Elizabeths campus in Southeast, Subido says she saw call takers distracted by huge TV screens that were meant to show local news but were sometimes blasting reality TV or sports. (Jeff Peck, a retired OUC director, says he saw the same thing.) Subido also says she saw many empty seats, the result of understaffing and high absenteeism. While OUC requires a minimum of 18 to 20 call takers during the day shift—and 15 to 18 at night­—Patterson’s audit found that staffing levels hovered around 14 to 17.

The audit also revealed problems with how calls were handled. Rather than use software tools to locate callers who were confused or unable to communicate clearly, call takers would continue to ask questions, wasting valuable time and making errors more likely. This led one consultant who worked on the audit to state that “an Uber driver can find you. A Domino’s pizza delivery driver can find you. 911 can not always find you.”

Similarly, call takers were supposed to use scripts to ensure that they asked the right kind of questions and got help to callers as soon as possible—for example, if someone called about a person who wasn’t breathing, there was a script for guiding that caller through performing CPR until help arrived. But too often, the audit found, call takers would ad-lib.

Subido says she tried to make changes. She shifted schedules, increased training requirements for new employees from 16 hours to 160 hours, and banned call takers from the common practice of “patching”—combining two or more radio channels in order to multitask when other callers were away from their consoles or hadn’t shown up to work.

To outside observers, it seemed like Subido was making a difference. During her tenure, Statter says, he uncovered only one death that he could attribute to a 911 mistake: 17-year-old Kyle Richards, who was dying from a gunshot wound in Benning Ridge as a call taker reportedly ignored the call’s automatic location data, a mistake Subido discussed openly in January 2022 testimony before the DC Council.

But within OUC, Subido says, she was stymied. According to Patterson’s audit, “cliques, bullying, and uncorrected inappropriate behaviors” were part of the agency’s workplace culture. Supervisors played favorites, Subido says, rewarding loyalty and angling for promotions. Not wanting to rock the boat, they avoided making significant changes, overlooked systemic problems, and tolerated subpar performance. The people who “make these horrific address errors,” Subido says, “are not held accountable.”

Subido cooperated with the independent auditors hired by Patterson, hoping their work would spur improvement. She also readily acknowledged mistakes. This made her feel out of place. Around her, she says, was a troubling culture of secrecy. Subido claims that superiors stopped her from speaking to the press, that senior staff tried to submit out-of-date data to tell a better story about OUC’s performance than was warranted by the facts, and that the agency was denying more than 80 percent of Freedom of Information Act requests coming from journalists and concerned citizens, often for clerical reasons that Subido saw as bogus.

The agency also had a blanket policy of declining to release 911 call audio to the public, which Subido says is unusual. “It was so foreign to me, coming from agencies where they would be the first to admit when something went wrong,” she says.

Often, interim agency directors take over the top spot permanently, and Subido says in her lawsuit that she received assurances to that effect from then–police chief Robert Contee, Fire and EMS chief John Donnelly, and deputy mayor Chris Geldart. But Subido’s suit also claims that Geldart warned her in spring 2021 to stop pursuing her concerns, to avoid getting fired by Bowser.

Roughly a year later, Bowser announced that Holmes would return as OUC director pending DC Council approval. The mayor’s office didn’t provide a public explanation for snubbing Subido, and several council members voiced shock and dismay. Subido became OUC liaison at DC Fire and EMS—effectively a demotion. In November 2022, she was placed on administrative leave. Subido felt blindsided. In her lawsuit, she claims Donnelly gave her a letter stating that her leave was due to an OUC investigation and told her he was unaware of any specific allegations against her. The following January, a city HR official called Subido to tell her she’d been fired.

Rumors have circulated about Subido’s workplace conduct, but neither the mayor’s office nor Subido’s attorneys have made any specific allegations public, and neither would confirm any scuttlebutt. In March 2023, Subido filed a lawsuit against Bowser and the city, alleging whistleblower retaliation. In the suit, Subido claims that OUC’s performance fell short of national standards, that it reported inaccurate and inflated performance numbers under Holmes, and that in a single day, dispatchers sent responders to the wrong addresses ten times. It also alleges that the city “repeatedly sought to conceal errors and mismanagement by OUC and to downplay serious, life-threatening—and often fatal—mistakes.”

Bowser has said Subido’s still-pending suit is “without merit.” Subido’s lawyers say she hasn’t worked since being fired, a steep fall after a 40-year career in public safety. Holmes spent ten months as OUC’s interim director before a lack of DC Council support led her to withdraw from consideration for the full-time job in December 2022. She was replaced by McGaffin, her number two, who currently heads the agency.

Under McGaffin, the drumbeat of complaints about OUC has continued. In her public letter to the director on July 2, Nadeau cited a “serious disturbance” in Columbia Heights on June 1 during which several of her constituents called 911 and no one picked up the phone. One caller told Nadeau she was put on hold for 20 minutes.

The Shadow Dispatch

On a Friday night in June, a handful of ambulances and fire engines were parked outside Union Market. Inside, DC’s firefighters sat at neatly set tables, dressed in their navy-and-brass finery. This was an awards ceremony, and the attendees were buoyant—flagging down servers for another pour of wine and whooping when members of their engine companies received shout-outs.

The most ecstatic cheers came when Washingtonians presented awards to the people who had saved their lives. A 14-year-old boy and his mother thanked the firefighters and paramedics of Engine 30, who had found him on a middle-school basketball court in July 2023, not breathing and without a pulse. He made a full recovery at Children’s Hospital. Eight days after his rescue, responders from Engine 33 freed a critically injured five-year-old girl trapped under a crashed car. She also made a full recovery and took to the stage with her mother.

Several more stories followed. At one point, DC deputy fire chief Daniel McCoy sidled back to a table where reporters were sitting. “With most of these incidents,” he said, “the FOC was involved.”

McCoy was referring to the Fire Operations Center, a little-known facility that’s become a vital player in DC’s 911 system. Located on the upper floor of a 92-year-old brick firehouse near Franklin Square, the center was launched in October 2022 with the primary purpose of coordinating emergency response to major events like protests and inaugurations.

Washingtonian visited the FOC on July 4, a holiday that’s akin to the Super Bowl for DC’s fire and emergency services. (This July 4, OUC reports that it answered 77.6 percent of 911 calls within 15 seconds.) Inside a room with desk space for about a dozen people, nine screens displayed dashboards, live feeds, and current 911 calls with event codes like firebrush and assaultnfi. Staffers and officials on hand emphasized that the center exists to facilitate communication among various public-safety agencies and provide redundancy during catastrophic occurrences like September 11 and January 6. “We get information, and we disseminate it,” said Lieutenant Jason Edwards, an FOC staffer.

But on normal days, fire-department sources tell Washingtonian, the FOC spends much of its time fixing the city’s 911 flubs. McCoy, a department veteran, says he used to listen to emergency-radio channels and interject whenever he heard an error from OUC. Today, FOC operators do the same. Drawn from a larger group of fire officers, these operators typically staff the center in groups of two and often dial callers back to get more information for responders.

“They have us monitoring the radio 24 hours a day,” says a current FOC operator, who asked not to be named out of fear of retaliation from Bowser’s office. “It’s a lot of shit for two guys, I can tell you that.”

Prior to OUC’s takeover in 2004, DC Fire and EMS had been in charge of all of its own 911 dispatch. As frustration with the new call center grew over the last decade, so did support within FEMS for retaking control. A 2019 pilot program testing that concept went well, and in August 2022, deputy mayor Geldart told the Washington Post that the city was considering handing over OUC’s dispatch function to the fire department. According to Subido, the mayor’s office was not pleased with that disclosure. Bowser quickly downplayed the possibility, and OUC retained its role.

Today, the FOC’s coordination work during major events has equivalents in other US cities—and in other DC entities such as the police department’s new Real-Time Crime Center, which also has dispatch capability. (Asked by Washingtonian if OUC’s well-publicized errors with Fire and EMS calls had affected the police, police chief Pamela Smith said “it has not been brought to my attention that that’s something that’s happening.”) By contrast, the FOC’s everyday efforts to correct OUC mistakes are highly unusual, Subido says. The former interim OUC director, who has compared notes with emergency-response officials nationwide, says she knows of no similar situation anywhere else.

According to the current FOC employee, each time FOC workers fix an error made by OUC—or step in to help confused fire battalions—they fill out a standard “communication tracking” form called a CD 1. These reports are submitted to their department’s OUC liaison and also make their way into end-of-shift reports.

When Washingtonian filed a series of FOIA requests for CD 1 forms and end-of-shift reports with OUC and FEMS, FEMS claimed it was “unable to locate” any such documents. (OUC did not respond.) The current FOC employee says the documents exist and that OUC mistakes happen constantly.

“It’s every day,” the employee says. “In the beginning, we filled [CD 1s] out at least once or twice or three times a shift, and then we just got tired of filling them out because they wouldn’t go nowhere. But if you looked into the file, you would stir up hundreds over the past two years.”

Filing those complaints, the employee added, feels futile: “The word that comes back is ‘We’re looking into it.’ But the other word that comes back is ‘You know, we can’t do nothing to them civilians [at OUC]. They’re untouchable.’ ”

“Political Incompetence”

The rain was too heavy, the runoff too severe. On a stormy afternoon last August, a flash flood burst through the glass wall of District Dogs on Rhode Island Avenue, Northeast, inundating the doggie-daycare facility with six feet of water.

Watching the destruction unfold through a remote camera, an employee who wasn’t working called 911 and said that people and dogs were stuck in the building. A supervisor directed the call taker to code the incident as a “water leak.” No help was sent. Three minutes later, another offsite employee called. This time, OUC responded—but because dispatchers still called the incident a “water leak” over the radio and didn’t mention that occupants were in danger, a rescue crew en route considered it a low priority and turned around.

Eight minutes after that, OUC received a call from someone inside District Dogs and recoded the incident as a “water rescue.” It took another five minutes to radio firefighters that people and animals were at risk. Ultimately, firefighters arrived 23 minutes after the first call. Working with staff members, they saved 20 dogs.

Ten others drowned.

The fiasco prompted a fresh round of outrage at the city’s 911 service. Can it be fixed? Last November, Nadeau introduced a bill that would have OUC call takers transfer all calls related to fire or emergency medical services to FEMS for dispatching—essentially reviving the fire department’s 2019 pilot program. Fire chief Donnelly has publicly opposed the idea, preferring to have his department work with OUC to improve the current system. But many frustrated firefighters support a takeover, and Nadeau says the bill was informed by input from former FEMS officials who feel the department is up to the task.

FEMS itself is an example that change is possible. A decade ago, its medical-response performance was so troubled that some suggested splitting the department into two separate agencies, EMS and fire. Under fire chiefs Gregory Dean and Donnelly and recently retired medical director Robert Holman, new leadership brought needed innovations—such as a nurse triage line that saves firefighters trips by determining which callers need immediate help and which are simply, say, hung-over—and slowly helped repair the department’s reputation.

To make similar strides, some experts say, OUC should focus as much on its people as its processes. That means better training, and also addressing the burnout behind inadequate staffing that in May and June of this year left the call center with too few workers during more than one third of its shifts.

Call taking and dispatching is hard work. Shifts last 12 hours. The stress can be corrosive. According to a recent national survey of public-safety workers by the US Marshals Service, rates of depression, anxiety, PTSD symptoms, and suicidal thoughts among 911 dispatchers are two to three times higher than those of police and fire professionals—and in some cases, more than ten times higher than in the general public.

Despite these demands, the starting salary for the city’s call takers is $50,200—about $8,000 less than for the same job in Arlington and roughly the same amount below what the Economic Policy Institute estimates is needed for a single, childless individual to achieve a “modest yet ad­equate standard of living” in DC. Nor are call takers eligible for the generous pensions available to firefighters and police officers. “We don’t think of 911 professionals as first responders—they’re classified as secretaries,” says S. Rebecca Neusteter, a public-policy researcher and an expert on 911 dispatch. “They’re not given the same sort of respect.”

While some firefighters and paramedics are exasperated with OUC’s rank and file, others in DC government blame Bowser’s office for 911 shortcomings. Instead of correcting mistakes, several sources told Washingtonian, the mayor has sought to minimize them, prioritizing public relations over public safety.

“If you sort of step back and go to the 30,000-foot level, what you see here is a failure of an administration to acknowledge the problem,” says Patterson, the city auditor. “Look at the mayor’s press conferences on this issue for the last three years and you will see the exact same line: We have a lot of calls, we do a great job, we’ve got great leadership. So there’s never even been an acknowledgment to victims’ families of the dire consequences that have resulted here.”

Asked about Bowser’s approach, Nadeau sounds bewildered. “Are you asking me to make it make sense?” she says. “I can’t make it make sense. This whole insistence on always being right is harming people.” The state of 911 in DC, she adds, is “the perfect storm of political incompetence.”