Caste study: The London Ambulance Service Computer Aided Dispatch (CAD) The London Ambulance Service's (LAS) 1992 computer aided dispatch (CAD) software system failure is one instance of the considerable negative effect that a small error in software can have on a large population of people. A careful examination of the events surrounding the incident, however, suggests that there was more to the issue than just an error in the software. Rather, the overall carelessness with which the application's development was approached from its conception set the stage for such a grand failure. The CAD system This section begins with a brief description of the 1992 crash and its aftermath. This is followed by a description of the development of the new system, introduced in 1996. The crash of the 1992 LASCAD system The LAS is the largest ambulance service in the world and covers an area of 620 square miles with responsibility for the seven million people who live in the area plus the many who commute or visit. The LAS comprises 70 ambulance stations, 700 vehicles (around 400 ambulances, plus helicopter, motorcycles, and other patient transfer vehicles), and over 3000 staff (including 670 paramedics and 300 control staff). On average, the Service responds to around 2500 calls per day (1500 of which are 999 emergency calls). The demand for emergency services has increased steadily over the years with an annual growth rate of around 15%. A new CAD system was introduced on the night of 26th October 1992 to replace the previous manual dispatching system. According to Beynon-Davies (1999), 'a flood of 999 calls apparently swamped operators' screens. It was also claimed that many recorded calls were being wiped off screens. This in turn caused a mass of automatic alerts to be generated indicating that calls to ambulances had not been acknowledged'. Operators were unable to clear the queues that developed and ambulances that had completed a job were not always cleared and made available, with the result that the system had fewer and fewer resources to allocate. Finally, at 1400 hours on the 27th October 1992 the system was unable to cope and LAS decided to terminate the system and revert to semi- manual operation. Calls continued to be taken via the system but the incident details were printed out and allocation was done manually, followed by mobilization of ambulances via the system again. This improved the situation and LAS was at least able to respond to emergency calls and continue to dispatch ambulances. This failure became known in the U.K. media as the 'crash of the London Ambulance system'. In the context of the definition of failure discussion above, the 1992 CAD system did not crash completely, although according to the Public Inquiry the problems 'cumulatively led to all the symptoms of systems failure' (Page et al., 1993). As a result the CE of LAS, who had championed the 1992 system, resigned. The next day a new CE, Martin Gorham, was appointed. He had been in the NHS (National Health Service) for about 25 years, mainly in hospital management, and had been director of corporate planning for a large health authority. Despite the change of CE it was not long beforefurther problems emerged. On 4th November 1992, the semi-manual system failed to print out calls and LAS was forced to revert to a fully manual, paper-based system, with voice or telephone ambulance mobilization. The Times (London) of 5 November 1992 reported a 25 min delay in dispatching an ambulance and senior management were forced to 'concede that the system could not cope with its task'. In operational terms LAS was now back where it was prior to the 1992 system. A Public Inquiry was set up by the government and its findings were published in February 1993. The Report (Page et al., 1993) was highly critical of the management of LAS. In relation to the programme of change including the implementation of the CAD system, the report stated that 'the speed and depth of the change was simply too aggressive for the circumstances. Management clearly underestimated the difficulties involved in changing the deeply ingrained culture of LAS and misjudged the industrial relations climate so that staff were alienated to the changes rather than brought on board'. The report made a series of conclusions and recommendations for the future of LAS. Despite the significant problems experienced, LAS was recommended to continue to seek a computer solution for ambulance dispatch but that 'it must be developed and introduced in a time scale which, whilst recognizing the need for earliest introduction, must allow fully for consultation, quality assurance, testing, and training' (Page et al., 1993). In relation to the management of LAS, a restructuring was recommended together with a range of new appointments. It was acknowledged that such recommendations had resource implications and the South West Thames RHA (Regional Health Authority), now responsible for LAS, was encouraged to devise a financial strategy to achieve this. The process through which requirements were gathered and specifications and designs were written had several major flaws. First, it seems that a LAS team - not a software development team - went through this process without attempting to consult ambulance operators, dispatchers, and other key users of the system. A basic understanding of the software requirements process suggests that leaving out key stakeholders is detrimental to the project and will result in an incomplete set of requirements. Gorham agreed that the LAS needed restructuring. He says, 'The simple fact was that the current structure was a complete obstacle to making progress. We didn't have the level of management resources that were needed. I think that's one of the reasons why my predecessor wasn't able to deliver what he set out to do. He just never had the amount of high level management resources you need to turn around a big high-profile, complex organization, which had drifted 10-15 years behind the time.' Gorham implemented a four divisional structure and created an executive board, consisting of the CE, Finance Director, Director of Personnel, Operations Director, four Divisional Directors, and a Deputy who also managed the Control Room. Gorham also created a planning and an IT function with lan Tighe appointed from the West Midlands Police as IT Director. Tighe in turn appointed Quentin Armitage as an IT developer. Meanwhile, the manual dispatch system continued to operate, but problems were still being experienced highlighted by the case of Nasima Begum in June 1994. The 11 year old had a liver condition, for which she was receiving regular treatment, but unfortunately her condition worsened and despite four emergency calls she had to wait 53 min for an ambulance, only to die of renal failure. The tragedy was compounded by the fact that she lived only two minutes from a hospital and that the only available ambulance was sent elsewhere, toA.-Which type of system was implemented here (FIT, NIT, or.EIT)? What makes you think that was the case?1 B.-Explain 2-3.of the 'complements' that had to be.in place.but were missing.in. the first-implementation of the IT system and therefore resulted in the total. failure of the implementation. C.- By drawing on two specific concepts.from the course (any.lessons), briefly. discuss what would have done differently if you were to design and implement this system effectively