Coroner makes 25 recommendations in Ornge deaths review

Ontario’s chief coroner has made 25 recommendations following a review of deaths of patients who were transported by the province’s beleaguered air ambulance service.

The expert panel, which was struck last August, reviewed deaths involving the air ambulance service over a six-year period between Jan. 1, 2006, and June 30, 2013. Ornge airlifts about 10,000 patients each year.

The panel screened hundreds of cases of which 40 required further review.

In 32 of the 40, the panel concluded that operational issues had no impact. In the other eight, the panel said there were five cases of possible impact, one case of probable impact, in which it was likely operational issues contributed to a patient’s death and two cases of definite impact, in which operational issues directly caused or contributed to the patient’s death.

In one definite impact case, a 22-year-old man had a history of drug abuse and sought medical help at a First Nations nursing station after a two-day drinking binge. He was treated and sent home, but returned to the station a day later when symptoms worsened. That was when he was airlifted to a community hospital in northern Ontario.

During the transport, the medical oxygen supply ran out before the helicopter landed at which time the patent had no vital signs. There were attempts to resuscitate him but he was pronounced dead on arrival at the hospital.

“Reviewers agreed that there was a definite impact on the outcome related to air transport/caregiver issues,” the report stated. “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 the error in oxygen flow rate setting.”

The coroner’s 25 recommendations relate to decision-making, response process, international transports, communication, aircraft/equipment and staffing among other categories.

Ornge CEO Dr. Andrew McCallum said in a release, “This report provides much valuable insight into ways we can improve patient care, and we are continuing to work on making the necessary changes to our operations.”

Health Minister Deb Matthews said her ministry will “act on” all the recommendations, and both she and McCallum said many have already been implemented.

“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,” she said in a release.

Ornge has been the subject of intense scrutiny in the past year for the management of its finances and the hefty $1.4-million compensation given to its former CEO Chris Mazza.

Click here to read the full report.

With files from The Canadian Press