Ornge reacts to coroner’s report
Ornge has said that it welcomes the release of the Expert Panel Report from the Office of the Chief Coroner, and has affirmed its commitment to act on the recommendations. The Office of the Chief Coroner explained that after screening ‘hundreds of cases in which death occurred following a request for an air ambulance’, in eight, operational issues had some degree of impact on the outcome.
Ornge, provider of air ambulance and related services for the province of Ontario, Canada, said that it welcomes the release of the Expert Panel Report from the Office of the Chief Coroner, and has affirmed its commitment to act on the recommendations.
In August 2012, the Office of the Chief Coroner established an Expert Panel to review deaths in which issues pertaining to air ambulance transport may have affected the outcome, and to identify themes and recommendations aimed at improving care and preventing similar deaths in the future; the Review of Ornge air ambulance transport related deaths was published on 15 July. The Office of the Chief Coroner explained that after screening ‘hundreds of cases in which death occurred following a request for an air ambulance’, 40 were identified as requiring further review. In eight of those cases, the panel concluded that operational issues had some degree of impact on the outcome, including five cases of possible impact, one case of probable impact and two cases of definite impact.
Dr Andrew McCallum, president and chief executive officer of Ornge, said: “I want to thank the members of the Expert Panel for their thorough and thoughtful review. 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.”
Considerable progress has already been made in the areas identified by the Panel, such as decision making, response processes, and aircraft/equipment, said Ornge. The service added that many of the panel’s recommendations have either been implemented or are in progress, including: installation of the AW139 helicopter interim medical interior to ensure CPR can be performed in the aircraft and to ensure that stretchers do not jam during loading and unloading; a new examination and certification process for communications officers in the Operations Control Centre to improve decision making and communications; a revised helicopter ‘autolaunch’ policy for on-scene response to ensure that aircraft launch immediately following a weather check.
“A number of the issues raised by the Coroner had been brought to our attention by frontline staff, and we took steps to act upon these prior to the release of the Coroner’s report,” said McCallum. “The recommendations from the expert panel will build upon this work.”
Ornge said it will report back to the Office of the Chief Coroner in the coming months on the progress made on the recommendations.
Dr Dan Cass, interim chief coroner and chair of the Patient Safety Review Committee, commented: “The front-line staff of Ontario’s air ambulance system provide excellent care to thousands of critically ill and injured Ontarians each year. Our aim in this review was to identify opportunities to make the system stronger and more effective, and to ensure that the people of Ontario have access to the best care possible when they need it most.”
Of the two cases where operational issues were considered to have had a definite impact, one concerned a teenager who had suffered a self-inflicted shotgun wound to his face. The panel found that a lack of effective sedation and chemical immobilisation of the patient allow him to self-extubate (remove a breathing tube) during transport. In the second case, the therapeutic oxygen flow rate was set at higher than usual during a flight, resulting in the oxygen supply running out shortly before landing, which resulted in the patient becoming hypoxic and suffering a fatal cardiac arrest. A critical care nurse had fallen ill and so an intensive care nurse was drafted from the sending hospital to fly with the remaining advanced care paramedic; the panel stated that the non-standard staffing configuration and the nurse’s lack of familiarity with the aircraft and equipment may have contributed to the error in the oxygen flow rate setting.