The Policing Authority has today published the Final Report on the Examination of the Garda Síochána review of the closure (including cancellation) of Computer Aided Dispatch (CAD) incidents. This is an independent, external examination of the circumstances, response and challenges presented by the invalid and unwarranted closure of CAD incidents and it outlines key findings and recommendations. This final report by Mr. Derek Penman follows an interim report, which was published in November 2021.

The Authority commissioned Derek Penman to carry out this examination in July 2021, having become aware in December 2020 of issues relating to the invalid closure of CAD incidents. Oversight of the issue continued in the interim and has been a key area of focus of the Authority’s work. This is reflected in the regularity with which the Authority has engaged with the Garda Síochána on this topic, including with the Garda Commissioner at meetings in public, as well as through briefings and site visits to regional control centres. Calling 999 is a critical point at which a victim or witness of a crime seeks a policing response that is effective, timely and empathetic. Callers are justified in expecting the call taker to be cognisant of the vulnerability of the person making the call, and their need to have confidence in an efficient Garda response. As a policing oversight body, the Authority prioritised this work to assure itself and be in a position to give external assurance to the public that the issues uncovered by the Garda Síochána had been appropriately dealt with and that any risk of reoccurrence was mitigated. It also wanted to give assurance that the public could have continued confidence in the quality of service being provided.

Mr. Penman’s examination took place in two phases. In the first instance, the Authority sought assurance that the Garda Síochána had acted quickly to understand the issues and implement effective solutions. The first phase of the examination focused on the Garda Síochána’s response and approach to reviewing cancelled and other CAD incidents, progressing victim engagement, and implementing technical, procedural and behavioural mitigations to avoid a reoccurrence of these issues. In November 2021, the Authority published an interim report on the examination which offered some high level assurances supported by evidence. It highlighted 25 key findings and made 13 recommendations. The Garda Síochána has begun work to address those findings and the Authority is engaging regularly with the senior Gardaí responsible for this work.

The final report published today follows the second phase of examination—the Call Recording Sampling Phase—which was commenced in May 2021 and concluded in early September. This phase consisted of Mr. Penman and his team listening to recordings of 210 calls made to the service in order to assess the quality of the response given to callers. This phase was delayed as the Authority and Garda Síochána worked through how the review would facilitate an assessment of the quality of the service provided and meet the requirements of GDPR legislation. 

The Authority regarded this second phase as essential. The second phase allowed for independent consideration of the quality of the response to callers—the consistency of tone and empathy with which victims were engaged, the patience and humanity of the response, and the impact of these qualities on the ability of the call taker to elicit critical information to guide a policing response. It would not have been possible to consider this from an examination of the paper and electronic files alone.

This Call Recording Sampling Phase provided further evidence to support the 25 Key Findings and 13 Recommendations made in the Interim Report and there are nine additional key findings and three additional recommendations in the final report published today, arising from this second phase of the examination. The Final Report builds on the Interim Report, which should be read in conjunction with it for a comprehensive explanation of call handling processes and the issues identified from the Garda Síochána CAD Review. Significant points arising from the examination are set out below:

• It was observed that overall, call takers are meeting the standards of service that the public should expect. Most call takers were polite, helpful, and professional. They generally delivered an effective and efficient service in often challenging circumstances and treated callers with patience and empathy. However, there were inconsistencies both within and across the four regional control rooms, with examples of excellent service from call takers as well as examples of poor service.
• Several incidents were identified with substantial shortcomings in call handling. Although there was the potential for serious harm to victims due to such shortcomings, no actual harm was identified from the sample examined in the call listening phase. However, it is not possible to determine whether serious harm occurred in incidents where callers or potential victims were not identified. Where callers were not identified, it was not possible to provide a service. In these cases, there is the potential that protection orders or TUSLA referrals were not put in place, crimes were not reported or investigated, and some offenders were not brought to justice. The final report, published today, includes examples of such shortcomings.
• There was very limited evidence of any supervisory checks over the CAD incidents selected for the call sampling phase. Policies and procedures were in place that should have identified unwarranted cancelled incidents. This would suggest that supervision, quality assurance checks and procedures for the performance management of individuals within regional control rooms and local stations were either not followed or not effective. This would appear to support the recommendation in the interim report that the Garda Síochána should undertake an urgent review to ensure that effective supervision, quality assurance and robust performance management processes for individual members are in place for all regional control rooms and local call taking and dispatch arrangements.
• There are incidents where the information provided by callers was not accurately recorded.

At times, this meant that Garda Síochána members were dispatched to the wrong locations, and callers could not be re-contacted. Although not quantified, there were occasions where the Garda Síochána was unable to provide a service, and in terms of the Garda Síochána’s CAD Review, some callers remain unidentified.

• Training in call taking and dispatch has been extensive, and members should have understood the limited circumstances when incidents could be cancelled. There is nothing to indicate that training was inadequate or has been a factor in cancelled incidents or other workarounds by members.
• There are incidents where call takers did not display sufficient skills or take sufficient time to properly assess the vulnerability of callers, particularly where communication is difficult due to language barriers, impairment, intoxication, medical condition or age. There are incidents where basic call-taking procedures were not being met, especially in terms of requesting, recording, and validating the contact details of callers, victims or incident locations.
• There are some incidents where Garda Members specifically requested that the CAD incident be cancelled, as well as incidents where callers were directed by call takers to attend local stations, rather than dispatching a Garda Member. In some cases, members requested dispatchers to cancel incidents which resulted in follow up activities being avoided.
• The issues around the ageing CAD system and other legacy technologies in use across regional control rooms are indicative of a chronic lack of investment. However, the cancellation of calls requires a specific action on the part of a call handler in order to cancel a call and therefore the technology was not deemed to be a significant contributory factor.
• The absence of call recording at local Garda stations is a serious vulnerability. It is made more acute by the lack of sufficient technical or procedural safeguards to ensure that such incidents reported to local stations are recorded and appropriately serviced.
• The Garda Síochána’s CAD Review process was a reasonable and proportionate response to the challenges identified from the cancellation of CAD incidents. The sheer volume of cancelled incidents required an iterative risk-based approach, and the focus on identifying harm and vulnerability was consistent with the Garda Síochána mission of “keeping people safe”.
• The Garda Síochána is to be commended for the detailed preparation of CAD Review incident files. The scale of this task should not be underestimated, especially the effort needed to secure electronic copies of 999/112 telephone calls and radio recordings.
• There was a nationally coordinated approach to victim engagement, delivered through divisional protective services teams or domestic abuse coordinators. This was good practice and ensured victim engagement was conducted by experienced staff and integrated with local support arrangements.
• The sampled calls were accurately captured in the CAD Review files and there was consistent evidence that the Garda Síochána sought to provide a service to those failed via a victim engagement process. As such, the sampling phase offers assurance over the accuracy and robustness of the CAD Review process undertaken by the Garda Síochána.

Based on the key findings from his report, Mr. Penman has recommended that the Garda Síochána concludes the CAD Review and ceases any further retrospective analysis of incidents. He recommends that the Garda Síochána concentrates its resources on improving the current call handling arrangements. While process, procedures and resourcing can be put in place, the assurance of a quality service requires a continuous, active and intrusive monitoring of adherence to policy and the quality of the engagement with callers. Oversight that gives confidence that this work is consistently being undertaken will continue to be a key area of the Authority’s work.

Policing Authority Chairperson, Bob Collins, commented:

“The 999 emergency call service is a crucial public service that people, often the most vulnerable, rely on in moments of crisis. It is essential that the Garda Síochána addresses the underlying issues identified in this report—issues including supervision, selection processes for specific roles, and performance management—so that the public can continue to have the confidence that it needs to have in the 999 emergency call service and will be assured of receiving the quality of service it deserves from its policing service. The Authority will continue to bring regular and rigorous oversight to this area.”

Mr. Penman’s report will be discussed at this afternoon’s meeting in public between the Policing Authority and the Garda Commissioner in Dublin Castle, which will commence at 3pm. The meeting will be live-streamed on www.policingauthority.ie, and those wishing to attend in person can register here.

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Notes to Editors

The Interim Update on the Preliminary Examination of the Garda Síochána review of the closure, (including cancellation) of Computer Aided Dispatch incidents can be viewed here.

The Prescriptive Guidance on the processing of Personal Data and Special Category Data for call recording sampling undertaken by the Policing Authority as part of the preliminary examination of the Garda Síochána review of the closure (including cancellation) of Computer Aided Dispatch (CAD) incidents can be viewed here.