In January 2006, the entire nation was shocked when New York Times reporter David Rosenbaum died after what the D.C. inspector general later called “an unacceptable chain of failure” by the city’s Emergency Medical System. Despite obvious trauma inflicted during a street robbery near his Northwest home, the emergency medical technicians who arrived first on the scene with a fire engine incorrectly assessed the semiconscious Rosenbaum as a low-priority drunk.

That was a fatal mistake. It took 23 minutes for an ambulance staffed by other EMTs to arrive on the scene. Instead of taking him to the nearest hospital, Rosenbaum was transported across town to Howard University Hospital, where he was left lying alone on a gurney for more than an hour.