The San Joaquin County (Calif.) EMS Agency has issued a 10-page investigative report on an Oct. 2006 incident that resulted in the death of the patient and the firing of two dispatchers. An address mixup created a 23-minute response delay, although the report said it’s not known if the patient would have been saved by a faster response. The investigation was apparently complicated by an on-going dispute between the Stockton Fire Department and the county EMS agency. A mis-pronounced street name by a CHP dispatcher started the incident, and an outdated mapping system contributed to the error. Download (pdf) the full report here.
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