to the operators becoming frustrated, which in turn led to an increased number of instances where crews failed to press the right buttons, or took a different vehicle to an incident than that suggested by the system. Crew frustration also seems to have contributed to a greater volume of voice radio traffic. This in turn contributed to the rising radio communications bottleneck, which caused a general slowing down in radio communications which, in turn, fed back into increasing crew frustration. The system therefore appears to have been in a vicious circle of cause and effect. One distraught ambulance driver was interviewed and recounted that the police are saying "Nice of you to turn up" and other things. At 23:00 on October 28 the LAS eventually instigated a backup procedure, after the death of at least 20 patients.An inquiry was carried out into this disaster at the LAS and a report was released in February 1993. Here is what the main summary of the report said:"What is clear from the Inquiry Team's investigations is that neither the Computer Aided Despatch (CAD) system itself, nor its users, were ready for full implementation on 26 October 1992. The CAD software was not complete, not properly tuned, and not fully tested. The resilience of the hardware under a full load had not been tested. The fall back option to the second file server had certainly not been tested. There were outstanding problems with data transmission to and from the mobile data terminals. … Staff, both within Central Ambulance Control (CAC) and ambulance crews, had no confidence in the system and was not all fully trained and there was no paper backup. There had been no attempt to foresee fully the effect of inaccurate or incomplete data available to the system (late status reporting/vehicle locations etc.). These imperfections led to an increase in the number of exception messages that would have to be dealt with and which in turn would lead to more call-b...
