CBC Investigates

Montreal ambulance service blames 'technical glitch' for failing to respond to call

CBC Montreal Investigates tracks down a 911 call that Montreal's ambulance service, Urgences-Santé, said it never received — leaving a Pierrefonds man having chest pains waiting in vain for paramedics.

Walid Zawahiri, 53, waited more than an hour for ambulance to arrive

Walid Zawahiri, 53, called for an ambulance when he was suffering a heart attack last Oct. 7, but Urgences-Santé sent two ambulances to another caller by mistake. (CBC)

A Montreal man is furious the city's ambulance service, Urgences-Santé, never sent him an ambulance after he first called for help.

Walid Zawahiri was watching TV at home in Pierrefonds on Montreal's West Island shortly after midnight last Oct. 7 when he began to have chest pains.

In a 911 audio recording obtained by CBC Montreal Investigates, Zawahiri, 53, can be heard struggling for breath.  

At some points, he has difficulty answering the operator's questions because he's in so much pain.

"I start talking to God and tell him, if you want me, I am ready to go," Zawahiri recalls.

Listen to an excerpt of the first 911 call on Oct. 7:

Walid Zawahiri's first call to 911 on Oct. 7. Urgence-Santé's operator says paramedics are on their way. 0:51

During the first call, the operator assured him several times an ambulance was on the way.

Zawahiri waited for an hour, but there was no sign of an ambulance or a fire truck with first responders. Although Zawahiri's symptoms had eased somewhat by then, he called 911 a second time to find out why the ambulance hadn't arrived.

"I'd love to know, when are the paramedics coming?" Zawahiri said in the 911 recording of the second call. "It's been an hour. Are they coming from Toronto?"

Listen to an excerpt from the second 911 call, an hour later:

A heart attack victim had to call Urgences-Santé twice before an ambulance was dispatched to him. 0:37

In the second audio recording, the operator appears to be checking, but training dictates staff quickly move on to triage the patient, which she did.

She told him she was sending paramedics.

When Zawahiri realized Urgences-Santé may have forgotten about him, he got angry and tried to cancel the ambulance. He said he'd go to the hospital the next day.

The operator insisted he let paramedics evaluate him. A fire truck with first responders arrived about 10 minutes after Zawahiri's second call, followed by an ambulance with paramedics. 

Lucky to be alive

They checked his blood pressure and heart rate and wanted to transport him to the hospital.

"I refused to go with them," said Zawahiri. "At that moment, I was so angry, I was so mad. I didn't want to see their faces anymore."

The next morning, Oct. 8, Zawahiri called 911 again with chest pains.

This time, Urgences-Santé responded quickly, and he was taken by ambulance to Sacré Coeur Hospital where he had an angioplasty, a procedure that unblocks arteries to the heart. 

Zawahiri said his doctor told him he was lucky to be alive.

Zawahiri contacted CBC Montreal Investigates after his release from hospital to help him find out why Urgences-Santé didn't send an ambulance the first time he called.

CBC was able to obtain Zawahiri's second Oct. 7 call along with the one he made on Oct. 8, as well as medical documents from Urgences-Santé — but not the original call he placed when he first started having chest pains.

Urgences-Santé said that's all it had.

CBC contacted Zawahiri's phone company to find proof that call existed. Although Zawahiri's 911 calls didn't appear on his cellphone bill, Rogers Communications was able to provide the time and duration of that emergency call — confirming he had indeed made three calls to Urgences-Santé.

Confronted with this information, Urgences-Santé gave CBC the audio of the first Oct. 7 call, claiming it couldn't find the call initially because it was logged to the wrong address.

Technical glitch

In the 911 audio recording of Zawahiri's first call on Oct. 7, the operator tells him an ambulance is on the way.

Urgences-Santé said it did dispatch an ambulance, but to the wrong address — that of a previous caller.

The chief of operations for Urgences-Santé's call centre, Vincent Brouillard, said a technical glitch wasn't discovered until CBC provided the precise time and date of a call that the ambulance service had previously said it never received. (CBC)

That caller, a person with similar symptoms, had just hung up when Zawahiri's call came in. Somehow, Urgences-Santé said, that person's address was transposed onto Zawahiri's file.

"We wrongly made the association of the voice with the wrong data or address," said Vincent Brouillard, chief of operations for Urgences-Santé's call centre. 

Brouillard said a new computer system was being updated at the time of Zawahiri's call. He blamed a "technical glitch" for the error and said the safeguards in place to catch these kinds of mistakes failed.

"Usually people catch it," said Brouillard. "Our team is well trained, and they catch it."

"But this particular situation, since it happened rarely to us, it kind of went, sadly, under the radar."

Red flag not investigated

Brouillard said soon after Zawahiri's first call on Oct. 7, there were suspicions an error had been made, because two ambulances were dispatched to the same address.

That address was the home of the person who had called a few seconds before Zawahiri.

We thought it was two calls from the same address,- Urgences-Santé call centre's operations chief Vincent Brouillard

When Urgences-Santé realized it had sent two ambulances to the same place, it cancelled the second ambulance — the one that should have gone to Zawahiri.

Brouillard said any concerns Urgences-Santé operators might have had that a second caller had been overlooked would have been dismissed when paramedics at the first location confirmed it had a patient being transported to hospital.

"We thought it was two calls from the same address," said Brouillard.

System-wide check

Urgences-Santé said it only retraced its steps after CBC Montreal Investigates brought Zawahiri's first call to its attention.

Based on the time CBC Montreal Investigates gave Urgences-Santé, technicians were able to track down the call.

"Nothing was reported before you (CBC) told us," said Brouillard.

When asked how paramedics could confuse the details of the previous caller's with Zawahiri's, Brouillard would only say the situations were similar. 

Callers are told to call back if anything changes.

"It was only an hour later he called back, and we could capture there was a problem with the initial call," said Brouillard.

Although Zawahiri insisted he had called an hour earlier, no red flag went up after his second call to indicate there had been a problem.

"Unfortunately, people didn't make the connection," said Brouillard.

An internal investigation is underway, and more technical checks are being put in place to track all calls from the moment they enter the system. Urgences-Santé is also improving staff training to catch these kind of mistakes.

So far, Urgences-Santé said it has discovered no other mishandled calls.

CBC Montreal Investigates

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About the Author

Leah Hendry

Leah Hendry is a TV, radio and online journalist with CBC Montreal Investigates.


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