Ornge air ambulances cited in deaths

Report links two cases to operational issues

TORONTO Operational issues at Ontario’s troubled air ambulance service contributed to the deaths of as many as eight patients transported by Ornge over a six-year period, the province’s chief coroner said Monday. They directly contributed to the deaths of two patients, probably had an effect on one case and possibly affected five others, according to a report by a panel of experts.

It reviewed 40 cases, which were among several hundred from January 2006 to June 2012 that were screened, said Dr. Dan Cass, the province’s interim chief coroner.

The operational issues included policies and procedures that led to a delay in launching an Ornge aircraft on call, a design flaw in an aircraft cabin, and the equipment used by paramedics, which affected the care of a patient, he said.

But Ornge does provide “excellent” care to patients across the province, he said. “The purpose was not about pointing fingers or assigning blame,” Cass added. “The purpose of this review was to learn from tragic deaths and to use that knowledge to prevent future deaths.”

Ornge transport directly contributed to the death of a 17-year-old boy in northern Ontario, who shot himself in the face and was being transported to another hospital outside the province, the report found.

Transport delays, including a mechanical delay in departure and transferring the teenager to a land ambulance, coupled with the lack of sedation of the patient had a “definite impact” on his death, the report said. The second case involved a 22-year-old man in northern Ontario with a history of alcohol and drug misuse who became ill after a drinking binge. The oxygen ran out during transport and despite attempts to resuscitate him, the man was pronounced dead at hospital.

Ornge and Health Minister Deb Matthews said they’ll act on all of the 25 recommendations in the report. Fifteen have already been implemented, Matthews said.