A cascading series of factors — a communication breakdown between 911 and EMS, the inability to get through to emergency services and a lack of available ambulances — delayed medical help more than 30 minutes for a Calgary senior who had been attacked by dogs.
The Health Quality Council of Alberta released an independent report Thursday detailing the emergency response to the fatal canine attack. Betty Ann (Rusty) Williams, 86, was mauled by three dogs while she was gardening in the city's Capitol Hill neighbourhood last June.
Her neighbours described to CBC News how they held the woman for about half an hour, alongside a bylaw officer, while waiting for an ambulance.
The incident prompted scrutiny of AHS wait times.
Charlene McBrien-Morrison, CEO of the Health Quality Council of Alberta, said there was no single action or activity that led to the ambulance's delay.
"It was a confluence of many things that came together on that day … some more significantly than others."
She said communication protocols were in place, but they weren't used correctly — "the tools that were there were either misunderstood or misused."
The report from HQCA — a provincial agency that operates independently from Alberta Health Services and Alberta Health — said EMS arrived 36 minutes and nine seconds after the 911 call.
The event was initially coded as non-life-threatening.
The Calgary 911 call taker — with the information that there had been a dog attack — assumed the scene was not safe and assigned police instead of EMS as the lead agency.
EMS dispatch did not speak directly to the 911 caller.
The report also found that the 911 call taker communicated information to EMS in a way that didn't follow an established process. EMS, in turn, used a manual card for dog attacks instead of a computerized version. If they had been using the computer program, it would have prompted questions about the senior's condition.
Had the response been upgraded to life-threatening, the report estimated that paramedics would have been on scene just after 14 minutes.
However, that still would have exceeded AHS's targeted response time for life-threatening incidents.
The report noted that the Southern Alberta Communications Centre was short-staffed that day, and demand for EMS exceeded the available resources. Only 31 of 38 (or 82 per cent) of ambulances assigned to Calgary were staffed, and EMS was in a red alert — meaning there were no ambulances available to respond to events.
Mauro Chies, interim president of AHS, said the event has had a far-reaching impact on those involved.
"We deeply apologize for the role the AHS had in getting the ambulance to the scene that day," he said.
A bylaw officer was on scene within minutes. He tried to make multiple calls to EMS but was unable to get through. Once EMS arrived, they went to the wrong location — to the front of Williams's home, not the alley.
Moving of EMS dispatch resulted in 'tension'
HQCA said moving EMS dispatch to a separate location appears to have resulted in "tension" between that agency and Calgary 911.
"When AHS EMS moved to a different physical location, many reported the relationship between the agencies became strained," the report said.
But the report said the consolidation of dispatch was not found to have contributed to the outcome of this incident or a contributing factor to response times.
"Whether people are in the same room or not, everyone's incredibly busy in that room. And their respective people are taking calls from their respective services. So to assume that just sitting together would have solved this, I think, is not something that we would have considered appropriate," McBrien-Morrison said.
The HQCA prepared recommendations for AHS, the City of Calgary and the Calgary Police. AHS has said it will immediately act on and implement its recommendations.
To address the incorrect coding and inability of the bylaw officer to provide information from the scene, HQCA recommends revising Calgary 911 policy on assessing scene safety, improving information collection about patients, and the creation or updating of policies to enable bylaw officers to interrupt radio traffic.
It also recommended improving co-evaluation between 911 call takers and EMS — which is when the agencies assess a call together.
Other recommendations touched on ways to address demand for EMS exceeding available resources, including diverting more calls to other EMS call centres in Alberta.
The Calgary Police Service said it has reviewed HQCA's report and will be looking at its own response.
The statement said the report made recommendations around using a Secondary Emergency Notification of Dispatch (SEND). The police service said its members were trained on SEND in February 2021.
SEND is a protocol meant to streamline communication between emergency personnel in the field to dispatchers.
However, HQCA said CPS communicated internally about the SEND protocol but "no confirmation was obtained to indicate front-line officers (CPS or bylaw) are trained in using the SEND protocol."
Early trauma response important, says doctor
Dr. Ian Walker, an emergency room physician and medical director of AHS EMS, said he doesn't know if the extra time would have saved Williams, but added that earlier response is better in trauma treatment.
"The sooner we get the trauma patients, the better they do, as a rule."
The three dogs that attacked Williams were a North American pit bull terrier mix, a North American Staffordshire mix and an American pit bull. They were owned by a neighbour.
In October, Calgary police — in consultation with the Crown prosecutor — determined that the necessary elements to support laying charges of criminal negligence causing death against the owners of the dogs were not met.
The HQCA report was originally slated for September but was delayed until January due to its complex nature.