Inquest jury handed proposals for fixing 911 system

The jury at a coroner's inquest into the death of an eastern Ontario woman who died after calling 911 has been handed proposals for sweeping changes to the way emergency calls are handled in the province.

Coroner's inquest looking into death of Casselman, Ont., woman

Kathryn Missen called 911 during a severe asthma attack in 2014, but it was two days before her body was found at her home in Casselman, Ont. (Missen family )

The jury at a coroner's inquest into the death of an eastern Ontario woman who died after calling 911 has been handed proposals for sweeping changes to the way emergency calls are handled in the province.

Kathryn Missen, 54, dialled 911 while suffering a severe asthma attack at her home in Casselman on Sept.1, 2014. She was found dead two days later after neighbours became concerned.  

The 911 operator at the other end of the line at the OPP call centre in North Bay, Ont., was unable to understand what Missen was asking for, and the call was transferred to Smiths Falls, Ont. An OPP constable eventually reached in Russell, Ont., neglected to check on her.

That officer was temporarily demoted.

The inquest is examining what role the 911 system played in Missen's death, and is also looking into how the system mishandled calls about a 2013 boating accident in Sudbury, Ont. in which three people died.

No ministerial oversight

On Tuesday, after more than two weeks of testimony, first in Sudbury and then in Ottawa, the jury was handed 34 proposals for reforming the emergency call system.

The proposals came from Missen's family, the lawyer to the coroner, lawyers for the city of Sudbury, and lawyers for the 911 dispatchers and the OPP constable involved in Missen's case.

"It's important that a light was shone on this case, and it has been a bright one," Prabhu Rajan, the lawyer for the coroner, told the jury.

Rajan said first responders, acting without malice, made mistakes; but he said the bigger issue is the gaps in the emergency response system.  

Firefighters, police and paramedics have protocols on how to deal with 911 calls, but Rajan noted there is no stand-alone legislation or ministry that covers standards for the system.

Kathryn Missen died in 2014 after she called 911 during an asthma attack which left her unable to speak more than a few words to the call taker. Her daughter Harriet Clunie particularly welcomed one of the recommendations presented at a coroner's inquest. 0:27

Call for working group

The proposals also include a call to do away with the primary tier that triages 911 calls before sending them to a secondary dispatcher, which is what happened with Missen's call.

Another key proposal calls for the creation of a provincial working group of experts, including front-line responders, to take the lead on overhauling the system.

That working group, Rajan said, should look at the following proposals:

  • Establishing a compatible computer dispatch systems so all 911 dispatchers and police officers can see the information taken from the caller.
  • A computer dispatch system that highlights critical information about the caller.
  • A radio call system that allows responders to speak directly to one another.
  • A "silent call" system, like one in Massachusetts, that allows a caller who's unable to speak to request fire, police or paramedics by punching a code into their keypad.
  • A system whereby people voluntarily register their medical emergency information to police, fire and paramedics so responders know what the 911 call likely concerns.
  • Consensus among police, firefighters and paramedics on emergency terminology and priority codes.
  • A standard first question for every 911 caller. For example: "Do you need police, fire or an ambulance?"

Kathryn Missen's sister said all her family's five recommendations have been covered in the proposals to the jury.

The jury could come back with its recommendations, which aren't binding, as early as Wednesday.