Chief coroner 'hopeful' Ornge will implement recommendations

After a two-day drinking binge, a 22-year-old man with deteriorating health was due to be transferred by Ornge air ambulance from a community hospital in Northern Ontario to a hospital in eastern Ontario.

Because of the sudden illness of a critical care paramedic, an intensive care unit nurse was sent along for the transfer, working with the remaining advanced care paramedic.

During the transport, the oxygen flow was set at 25 litres per minute instead of the typical 15 litres per minute. This resulted in the medical oxygen supply running out before landing, and ultimately the patient's death.

This is one of two deaths between 2006 and 2012 where operational issues at Ornge air ambulance had a “definite impact” on the outcome of the case, according to a July 15 report by an expert panel struck by the Office of the Chief Coroner.

The report said the “non-standard staffing configuration, and a lack of familiarity of the accompanying registered nurse with the equipment and aircraft, may have contributed to the potential for error in the oxygen flow rate setting.”

In another case where the panel said there was a definite impact, a 17-year-old boy who shot himself in the face wasn't properly sedated as he was transported, and pulled out his airway tubes, leading to his death.

There were also transport delays associated with the boy's case.

After screening hundreds of cases in which there was a death following a request for an air ambulance, 40 were identified by the expert panel as requiring further review.

The panel, which was led by Dr. Craig Muir, the regional supervising coroner for the north region in Sudbury, concluded that in eight of those cases, operational issues had some degree of impact on the outcome.

This included five cases of possible impact, one case of probable impact and two cases of definite impact.

The report makes 25 recommendations to improve safety within Ontario's air ambulance transport system.

The recommendations, directed towards Ornge and the Ontario Ministry of Health and Long-Term Care, cover areas such as decision-making, the response process, communication, equipment, staffing, training and quality assurance.

While staffing did play a role in the case of the 22-year-old man, for example, it was an unusual circumstance, said the province's interim chief coroner, Dr. Dan Cass.

A more common staffing circumstance involved paramedics working overtime, and then having to start their next shift a few hours late because of provisions in their collective agreement.

“What was happening in some of the cases was there was not an effort to backfill those paramedics for the first few hours of their shift,” he said.

“So that meant the aircraft just wasn't available for those few hours. So there was definitely a staffing issue in some of the cases. We made a recommendation around that.”

Ornge, which was created in 2005, has been in the spotlight for the last few years after corruption and spending irregularities were uncovered at the air ambulance service. The organization has since been restructured.

When asked if he thinks any of the deaths had anything to do with some of the well-publicized issues at Ornge, Cass said it wasn't the panel's place to make any judgements about that.

He did said he hopes the all of the recommendations will be implemented. “We're hopeful that the ministry and Ornge will be positively disposed to the recommendations,” Cass said.

Ornge president and CEO Dr. Andrew McCallum said thanked the members of the expert panel for the report.

“This report provides much valuable insight into ways we can improve patient care, and we are continuing to work on making necessary changes to our operations.”

Minister of Health and Long-Term Care Deb Matthews said in a press release said the ministry and Ornge will act on all the recommendations in the report.

“In fact, under Ornge's new leadership, a number of the recommended improvements have already been made, based on the advice of the auditor general, frontline staff and others,” she said.

“As a result, 15 of the chief coroner's 25 recommendations have been implemented, and progress has been made on four others. We are committed to taking action on all of the remaining recommendations to ensure we have the safest possible air ambulance system, and will report to the chief coroner on our progress.”

While Nickel Belt MPP France Gélinas said she's happy the province has already taken action on many of the recommendations, she adds it's important not to forget how long they ignored the situation at Ornge.

The NDP's health and long-term care critic said her party and the ministry received many complaints about Ornge starting in about 2008, but the government never did anything about it.

She said the report is a vindication to the families who came forward and complained.

“They were right to complain,” Gélinas said. “They were right to say things should not have gone that way, and now the report proves them right.”

Fixing the problems at Ornge is especially critical for Northern Ontario, which, because of its remote nature, relies on air ambulance service in a way that Southern Ontario doesn't, she said.

In some cases, the Ornge bases in the north are barely staffed when they're at full complement, which meant if anyone gets sick or goes on maternity leave, there isn't enough coverage, Gélinas said.

“With the the problems at Ornge, there was the corruption and the abuse of money and the abuse of power,” she said.

“That had repercussions on the quality of care in terms of the understaffing and the faulty response process ... All of those have a bigger impact on Northern Ontario than they do elsewhere.”