Investigator Blames Ornge in Transport-related Deaths

 - August 4, 2013, 1:55 AM

A little more than a month after Ontario’s provincially funded air ambulance service Ornge suffered a fatal crash, the Province’s coroner has released the results of a special investigation into 40 Ornge patient transport-related deaths between 2006 and 2012. Operational errors at Ornge contributed to eight of those deaths, according to the July report, which also made 25 recommendations to improve service at Ornge.

Ornge has been under investigation by Canadian law enforcement and a provincial parliament committee for nearly two years for various financial dealings and other alleged improprieties. Last year most of its executive leadership either resigned or was fired by the provincial minister of health. Ornge has also drawn widespread criticism for operational incompetence and is currently afflicted by a pilot exodus and other problems as new leadership attempts to improve operations. The service operates a fleet of 10 AgustaWestland AW139s and five Sikorsky S-76s as well as 10 Pilatus PC-12s. One S-76 and its four-man crew were lost after a fatal crash near Moosonee on May 31.

All 40 of the cases reviewed revealed some sort of deficiency at Ornge; however, the coroner concluded that in 32 of them, “the identified issues related to air ambulance transport had no impact on the outcome” as “the patient’s injury or illness was deemed so severe” that “the outcome of patient death would have been unchanged even if the air ambulance transport had been conducted in an ideal way.” In the remaining eight cases deficiencies were credited in causing patient deaths along a sliding scale of possible, probable and definite impact. These included significant delays in dispatching aircraft because of crew shortage or maintenance issues, poor communications and decision-making, and operational negligence such as running out of patient oxygen while in flight.

The coroner cited Ornge’s failure to adhere to its own procedures and manuals in 29 of the 40 cases reviewed.

The coroner’s report was not comprehensive due to a lack of complete data. The report noted, “The ability to identify cases for inclusion in this review was hampered by the fact that deaths within 24 hours of transport are not routinely captured by Ornge. There did not appear to be consistency in the way that cases were identified and reviewed by both Ministry of Health and Long Term Care and Ornge.”

This caveat drew immediate fire from Ornge’s chief critic in the provincial parliament, MPP Frank Klees. “We will never know the true impact of Ornge mismanagement and the ministry [of health’s] failure to oversee its operations properly. It’s concerning that the report acknowledges that not all cases in which Ornge operations were directly responsible for patient deaths may have been captured in this review.”

Klees and others have called for the privatization of Ornge’s air operations. Before the formation of Ornge in 2005, the Ministry of Health contracted exclusively with private air ambulance companies throughout the province for medical lift.

Over the last five years Ornge has received more than $730 million in public funds and has issued bond debt for $300 million more to acquire the PC-12s and AW139s to replace the 30-year-old S-76As purchased from Canadian Helicopter, originally purchased as interim lift while the AW139s were added to the fleet. However, Ornge was forced to keep six S-76s to “ensure sufficient aircraft availability throughout the province,” according to an Ornge spokesman. He denied that this had anything to do with Ornge’s ability to maintain the AW139s.

However, Mike Trottier, a former Ornge training captain, told AIN that the decision to keep the S-76s was driven by Ornge’s inability to contract successfully with private air ambulance providers in the more remote parts of the province as well as a need to base two AW139s each at busier bases to provide redundancies. “They [Ornge] fundamentally miscalculated on the AW139 and the maintenance attached to each aircraft. It became quite clear as the fleet was rolled out that you needed two aircraft at any particular base to back fill for each other.”

An Ornge spokesman said the service has already implemented more than half of the coroner’s recommendations. They covered the area of decision-making, response processes, international transports, communication, aircraft and equipment, staffing, training and investigation/quality assurance.