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Two deaths directly linked to Ornge operational problems: Coroner

By Antonella Artuso, Queen's Park Bureau Chief

Dr. Dan Cass, Ontario’s interim chief coroner and chair of the Patient Safety Review Committee, speaks about his report on Ornge Monday, July 15, 2013, at Queen's Park. (ANTONELLA ARTUSO/Toronto Sun)

Dr. Dan Cass, Ontario’s interim chief coroner and chair of the Patient Safety Review Committee, speaks about his report on Ornge Monday, July 15, 2013, at Queen's Park. (ANTONELLA ARTUSO/Toronto Sun)

TORONTO - 

The tragic deaths of two young men are directly linked to operational problems at the province’s Ornge Air Ambulance Service, a coroner’s review has concluded.

Dr. Dan Cass, Ontario’s interim-chief coroner and chair of the Patient Safety Review Committee, said both men may have survived had the air ambulance service not experienced delays, communication problems, equipment issues and inadequate staff training.

Of 40 Ornge cases reviewed, an expert panel found operational links in eight deaths.

“This review, like all death reviews in coroner’s inquests conducted by our office was about fact-finding, not fault-finding,” Cass said Monday, noting the problem deaths represent only a tiny fraction of Ornge cases.

“The purpose of this review was to learn from tragic deaths and to use that knowledge to prevent future deaths.”

The review, which was released Monday, concluded that operational problems at Ornge had a “possible” impact on the deaths of five people, a “probable” impact on the death of a 50-year-old man, and a “direct” impact on the deaths of a 17-year-old male with a self-inflicted shotgun wound and a 22-year-old man in distress after a two-day drinking binge.

The coroner’s office reviewed all Ornge-related deaths between Jan. 1, 2006, and June 30, 2012, following up on concerns raised that the crucial emergency service struggled with bad management.

In the case of the 22-year-old man, the medical oxygen supply ran out before the aircraft landed and he died of adult respiratory distress syndrome.

The 17-year-old youth had managed to remove a breathing device, and staff struggled for 25 minutes to put it back in, and respond to a profound lack of oxygen and cardiac arrest.

The report concluded a delay in coordinating a transfer to a land ambulance, coupled with a lack of effective sedation and chemical immobilization of the patient, definitely impacted his death.

Ornge has been under the spotlight since it was revealed that under former CEO Chris Mazza, the organization had become a complicated corporate maze. Staff complained that their concerns about management and operations were ignored.

All aircraft should permit paramedics to perform resuscitation, and stretcher locking mechanisms that jam should be reviewed, the report said.

Ontario Health Minister Deb Matthews said Ornge senior management committed to implementing all the recommendations in the review. Ornge has already implemented 15 of the review recommendations.

PC MPP Frank Klees said Matthews and her staff defended Ornge even as witnesses testifying at a government committee into the air service claimed lives were at risk.

“This report confirms what we’ve been saying for months and what the minister has been blindly and irresponsibly denying,” Klees said.

NDP MPP France Gelinas said the report should provide some small comfort to families who claimed all along that loved ones died as a result of the troubles at Ornge.


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