Flaw In Emergency Response System May Have Killed Hundreds
Hugh Pickens writes "The Telegraph reports that a flaw in the way emergency response software was set up to handle Category A responses in Great Britain may have cost hundreds of lives over the past ten years. Most ambulance services use an international computerized system designed in America and in the US version, a fall of more than 6 feet receives the maximum priority response. However, the government committee which governs its use in Great Britain decided that such cases should be deemed less urgent, and excluded from an eight minute category A target response time. If a call involved a fall of more than 6 feet it was designated a lower priority 'category B response' despite the presence of life-threatening conditions which were supposed to receive the most urgent category A response. The flaw came to light after Bonnie Mason, 58, fell 12 feet down the stairs and died from a head injury after emergency controllers in Suffolk failed to identify her situation as 'life-threatening.'"
The summary sounds like "we underestimated how dangerous a medium distance fall can be, so we didn't have the correct priorities and more people died than could have". That isn't really a flaw in the algorithm, it's just a flaw in one specific parameter in the algorithm.
Because there were two things which went wrong:
1) falls from over six foot were deemed to not be that serious but also
2) a computer error (in program or configuration) caused that to override anything else.
That is, under the decisions made by the bureaucracy the rules should have said:
1) if someone has fallen from a great height it is a type A (highest class) emergency
2) if someone has fallen from a moderate height it is a class B emergency unless there is something else which elevates it to a class A
3) if someone has fallen from ground level (slipped or tripped), it is a class B emergency unless there is something else which elevates it to class A
4) if someone is having trouble breathing, it is a class A emergency
5) is someone is bleeding profusely, it is a class A emergency
(etc).
The rules as implemented by the system actually effectively said:
1) if someone has fallen from a great height it is a type A (highest class) emergency
2) if someone has fallen from a moderate height it is a class B emergency
3) if someone has fallen from ground level (slipped or tripped), it is a class B emergency unless there is something else which elevates it to class A
4) if someone is having trouble breathing, it is a class A emergency
5) is someone is bleeding profusely, it is a class A emergency
(etc).
Note the shortened version of rule 2 and why this is relevant: moderate falls were being categorized as class B even when there were other risk factors. In the example case, we had an ambulance which was on its way to treat a woman who had fallen a moderate height and was bleeding profusely. It was diverted to instead help a woman who had slipped and fallen and was having trouble breathing because the first was classified as urgency level B and the first as urgency level A. This is clearly an error in either the software code, configuration, or the use of the program (most likely the configuration, I would guess, but that's just speculation on my part).
The committee's decision was that moderate falls shouldn't automatically elevate to class A. In practice, the system was assuming that moderate falls always were class B. So something was going wrong with the program, its configuration, or its use.