Flawed 111 system causing deaths and injuries - police documents

The government was warned a year ago that the 111 emergency call system is so old, slow and fragmented that it is causing deaths and injuries, police documents show.

But the Labour government dropped a project last August to replace the system, which is shared between police and Fire and Emergency.

The shortcomings of the 25-year-old system have been revealed in papers newly released under the Official Information Act, which show both agencies made the plea that there was an "urgent" and "pressing" need to replace it.

In a statement, Police Minister Mark Mitchell said: "I have been made aware of the issue, it has become obvious to us as the incoming government the police have not had core functions funded properly and I am working with the police executive on solutions to that."

A major flaw in the system is that it can only take phone calls, not text or video. It is also unable to liaise with social media platforms, and has poor integration between apps.

In one example, a woman was stabbed to death by a partner who overheard her making a 111 call.

"A modern [111] solution could have enabled [the woman] to notify police by a method other than a voice call which [the man] would not have detected."

In other examples:

• A man drowned at a beach in the time it took an ambulance and paramedic to get there after a 111 call to them - when police and Surf Rescue at the same beach were not alerted by the fragmented system.
• Firefighters were called out by 111 to help a woman tend a man who had collapsed when confronted by a shooter. But the system did not let police who were hunting the shooter know they were there. "The frontline FENZ responders and [the woman] are unaware of the danger they are in," a business case said.

These were outlined briefly in an initial business case to replace the old system called Card, accepted by the Cabinet a year ago and endorsed by half a dozen police executives.

The police on Tuesday morning told RNZ the system continued to work "despite the current challenges" and they had improved parts of the Computer Aided Dispatch or CAD component, around security and patching.

"We acknowledge where manual processes are used there is some risk of human error; we are focused on improving processes within the confines of our current systems," deputy commissioner of operational services and road policing Jevon McSkimming said in a statement.

The initial business case said restriction to phone-only requests and poor integration between apps and agencies was "risking lives, health and wellbeing."

"There is no margin for error in this service: failure to receive a call for help, or to send appropriate help to the right location, can literally be a matter of life and death."

There was evidence of an increase in calls "resulting in 'serious incidents' (avoidable death or injury)".

"The public may not receive timely help when they need it, and frontline responders could find themselves attending dangerous incidents without pertinent situational information and without adequate support."

The system broke down 59 times in the year 2021-22.

A fault in mid-2022 could not be found for 20 days, while calltakers deployed work-arounds that put them under "significant" pressure.

The system's inability to receive texts, video or social media communications led to poor assessment of how bad an emergency was - "eg finger injury vs severed hand, small fire vs major scrub fire".

Prime Minister Christopher Luxon said the government was asking police to find efficiencies to make savings to put into the likes of the 111 system.

"We know there are challenges to that triple-one system, I know the Minister's all over it," Luxon told Morning Report.

Making savings, and making new investments, were not mutually exclusive, he said.

"What we're asking the police to do is to go back through their back-office functions, look at their use of contractors and consultants, see whether there are inefficiencies, programmes that are not working, recycle those funds to put it back into the front line again.

"Essentially, we're asking every government department to generate savings.

"In some cases we are actually wanting to make sure those savings are then recycled into frontline services for key portfolios, and in other cases those savings need to be generated."

Briefing to minister calls system 'cumbersome'

Mitchell was told by police in a briefing to the incoming minister in November that police "have critical back-end ICT applications" like the 111 system "that require significant modernisation".

The system was increasingly not getting locations right.

"It is cumbersome and often inconsistent between agencies ... Mapping information is disparate, unintegrated, and inconsistent."

The agencies said they needed to reduce lost or abandoned 111 calls, as the number of 111 calls doubled over the past two decades.

Card was "already experiencing failures with some taking extended periods of time to trace and resolve ... Less secure old technologies and a patchwork of disparate systems risks privacy and security breaches and unplanned outages."

The risk was not just to 111 callers, but to the officers and other responders.

"For example, identifying the right location to deploy resources is the most important piece of information, and it is often inconsistent between agencies due to incompatible solutions and the inability to consume or share multi-source situational awareness information."

Unplanned outages due to the complex platform created "risk to the safety and wellbeing of New Zealanders and frontline responders," said the papers.

"Planned outages are lengthy and error prone, which affect operations."

The last time Card was upgraded in 2018/19, it forced the police's mobile responder app offline for an extended period, even though frontline officers relied on it.

Card did not work well across police and FENZ, while the two ambulance services, St John and Wellington Free, were even further removed with a separate callout system.

The Communications and Resource Deployment (Card) system is not a computer application. It is a physical system of multiple different items made up of software and hardware (including CAD, radio/voice console, telephony, standard operating procedures (SOPS), PCs/laptops, screens, radio equipment etc.) that make up a system for the deployment of resources in response to emergency incidents.

The papers date to around the time Cyclone Gabrielle was hammering the North Island.

"A modern replaced Card solution would significantly enhance the ability of the emergency service agencies to collaborate and coordinate their response to an event such as Cyclone Gabrielle," said a briefing to the Police Minister.

Detailed costings spanning 13 years from 2023 to buy and implement a whole new high-tech system across police and fire by 2027, and then the ambulance services by 2029, are laid out in the reports.

However, all the costings have been blanked out by police in the OIA response.

Ministers approved the initial business case, and ordered a more detailed one.

The project made it as far as the 'Significant Investments Track' for the 2023 Budget - but by August had been derailed by "tight fiscal constraints and competing pressures", the previous government told RNZ.

But an allied $1.4 billion upgrade of the Public Safety Network is going ahead.

This rolls out digital radios, so power cuts and cellphone outages do not cut off responders.

A replacement Card system was meant to fit in with this.

"The replacement Card solution will leverage the new infrastructure platform the PSN will provide to deliver more effective emergency services."

A question from the Prime Minister's office expressed puzzlement as to why the two emergency comms projects were not being done together, but the agencies said they offered separate benefits.

They told the lawmakers that if the Card budget bid failed, it would likely scupper any sector-wide solution and expose individual agencies to a lot of financial burden.

Police do have a 111 text system for the deaf or hearing-or-speech impaired that must first be registered online.

Police did not respond on Monday to RNZ's request to outline in what ways, if any, they have improved Card or reduced the risks of badly handled calls, since these reports came out.

Earlier they said they were looking at replacing a part of Card that would talk to the police radio network within the PSN, once it is ready.

They also said the agencies and ambulance services were working on ways to share information about incidents where more than one emergency service was required. It is not clear where that has got up to.

FENZ takes 350,000 calls a year, and uses Card to despatch crews to 85,000 emergencies; police handle 1.4 million 111 calls a year and 1.8 million '105' calls , a quarter of which are upgraded to an emergency.

In the police statement, McSkimming said they had business continuity plans to cope during Card outages.

The systems were still supported and maintained.

But it was "highly customised, and ensuring it's future-proofed and able to properly integrate across other emergency services is important. This is why potential investment remains under active consideration", he said.