Dane County's emergency dispatch center has kept incomplete and disorganized records of police complaints about its shortcomings, limiting its ability to prevent potentially life-and-death mistakes such as those that happened at the 911 center the day Brittany Zimmermann was killed.

Local police, fire and emergency medical workers are part of the problem -- many do not file formal complaints about 911 mistakes, instead relying on casual communication with center officials to correct shortcomings.

But even problems that are communicated in writing are not systematically being recorded, which experts say would allow dispatch center managers to spot troubling patterns and intercede with training.

Madison police, who sharply criticized the dispatch center in the Zimmermann case, and who said problems there were longstanding, were alarmed about the lack of recordkeeping, which came to light in the county's response to a request under the state Open Records Law.

"We all were dumbfounded," said Madison Police Capt. Carl Gloede. "Whether they're complaints or concerns, as a professional organization, you shouldn't be afraid to document your shortcomings, because they are a means of improvement."

Gloede, the police department records custodian and its representative on the county dispatch center's oversight board, said he had assumed all complaints were included in summary sheets that are regularly provided to the board.

Madison police had raised several concerns in 2007 through e-mail and phone calls, but none of them showed up in documents obtained by the Wisconsin State Journal through an open records request.

County officials responded to the request by providing records that showed there were 105 complaints between 2001 and 2007. The county provided supporting e-mails and complaint forms for some of those years, but said it would take thousands of dollars of staff time to find others.

Operations Manager Rich McVicar explained to Gloede in an e-mail last week that agency concerns "are normally communicated by various means to the extent necessary to handle them. We do not maintain an index or log of such things."

By county ordinance, "the center board shall review quarterly a report prepared by the director regarding the center's training plan and complaints concerning the center's operation."

McVicar said he doesn't know if the center's practice is a problem.

"What we present is intended to follow the ordinance," McVicar said. "I don't think we've been presenting it as a comprehensive look at performance that quarter."

The Zimmermann homicide on April 2 put a spotlight on 911 operations after the center failed to return a call from the UW-Madison student's cell phone that came in at about the time she was stabbed to death. When police found out about the call, the dispatch center supplied inaccurate information about it that led detectives down a blind alley for several weeks. No arrests have been made in the case.

Consultant to be used

Immediately after the 911 gaffes were revealed, Dane County 911 Director Joe Norwick said that such mistakes happened rarely.

In contrast, County Board Chairman Scott McDonell said last week that the county is hiring a consultant to audit dispatch operations because it's clear the 911 center doesn't know how often errors like those in the Zimmermann case happen.

"One of the reasons we want to bring in a consultant is to see how we measure up and see if we're following best practices," McDonell said.

The 911 center provided the County Board with the same summary of complaints from 2007 that was presented to the 911 board. The information reassured many board members that there were only 21 complaints filed out of more than 600,000 calls.

But as Madison police discovered, the complaints log doesn't tell the entire story.

The complaint process, both formal and informal, served as the only systematic quality control check on the 911 center's police calls until recently.

For the last month, in response to questions following the mishandled call from Zimmermann's cell phone in April, the center has begun screening 3 percent of all 911 calls for quality control. A quality assurance team reviews the calls and makes sure protocol was being followed. About 650 calls are being screened each month, including 200 that were already being screened, McVicar said.

Glaring error in 2002

One of the most glaring errors at the 911 center happened in 2002. A dispatcher sent a police unit, rather than a fire truck, to investigate a report of smoke at a restaurant in downtown Mount Horeb. The fire response was delayed 17 minutes, Schubert's Cafe and Bakery burned down, and the dispatcher was fired.

But annual complaint logs provided to the 911 oversight board contain no mention of the incident.

Mount Horeb Fire Chief Chuck Himsel said he never filed a formal complaint with the 911 center. Instead, he did what he usually does when a problem arises -- he called the center and talked to a supervisor.

"I just didn't want the Mount Horeb fire department and EMS to be known as a whining group," Himsel said. "I don't know that I have ever filed a complaint against the 911 center formally. The reason for that may or may not be obvious, but those are people we work with on a day-to-day basis."

At the same time, Himsel acknowledged that if nobody registers complaints, those who oversee the 911 center "can be ambivalent to the issues and say Nobody has said anything so far.'"

Middleton incident

"We make mistakes here," said Lt. Noel Kakuske, of the Middleton Police Department, "so we don't want to be overly zealous in pointing out mistakes that others have made."

Kakuske e-mailed several concerns to the dispatch center, then filed six of the 21 formal complaints logged by the dispatch center last year. Most had to do with the 911 center not notifying Middleton police about an incident after sending fire or ambulance service.

Review of the incidents found that 911 dispatchers were busy with other calls, which was also a factor in the Zimmermann case.

Kakuske's e-mail said 14 such incidents had occurred in a two-month span, but after consulting with his chief and McVicar, Kakuske agreed only to file the six as formal complaints.

"It had happened in the past and we had mentioned it," Kakuske said. "I think they had thought they had taken care of it before, but it didn't take."

Since filing those complaints, the issue hasn't resurfaced, Kakuske said.

Kakuske said the Middleton Police Department tracks all complaints from residents. Formal complaints must be signed by the citizen, but informal complaints are treated the same and tracked for quality control purposes.

"If you're interested in improving your service, you take all the complaints" and keep track of them, Kakuske said.

'An official complaint'

Middleton EMS Director Steve Wunsch complained by phone in 2007 after a 911 center employee tried to dispatch an ambulance that was already in the field.

"Normally I don't like to make waves, but this sort of thing has been happening far too often lately," Wunsch wrote in an email to McVicar. "I guess it time to log this as an official complaint so we can begin to track the frequency of any reoccurrences."

Wunsch said in an interview that the explanation he received for the error was "perfectly understandable." He also emphasized that his reference to "this sort of thing" did not mean that the other occurrences were serious enough to warrant a complaint.

"It is rare that I ever encountered a situation serious enough to warrant filing an official complaint," he said.

Developing a form

McVicar said user agencies are always asked if they want to file a formal complaint with the 911 center. The center also has been developing a complaint form for its Web site for citizens.

National experts say that paying proper attention to complaints is an important quality assurance practice, but random sampling of police calls is the primary way to maintain a top-notch dispatch center, said Rick Jones, operations issues director for the National Emergency Number Association, a national 911 best practices advocacy organization.

"In a quality assurance program, that doesn't just mean you rely on complaints," Jones said.

In June, NENA, along with the Association of Public-Safety Communication Officials (APCO) Institute, PowerPhone and the National Academy of Emergency Dispatch -- private and nonprofit organizations that develop emergency dispatch protocols -- published guidelines recommending that call centers develop compliance scores for each dispatcher and the call center as a whole.

Complaints can serve as a way to improve operations at law enforcement agencies, said Michael Scott, a UW-Madison law professor and former police chief.

"The patterns of complaints are analyzed to see if they suggest any improvements to policy, training, equipment, staffing, etc." Scott said. "In some communities, external citizen oversight bodies, such as auditors, review complaints and investigations for sufficiency and for wider ramifications."

Fitchburg Fire Chief Randy Pickering, who sits on the 911 board, said filing a formal complaint has the connotation of accusing the 911 center of wrongdoing, when in fact the errors are more day-to-day operational issues. But not keeping track of the informal concerns can hamper the center's ability to improve its service.

"There is value in looking at trends of what I would call training issues," Pickering said. "What it comes down to is when you start to see a particular issue happening with more frequency, then what you need to do is dig into it and figure out do we have a training issue, do we have a protocol issue, or is just an individual issue where a particular person is not getting it right."