Ontario's chief coroner says that operational issues at Ornge — the province's air ambulance service — contributed to the deaths of as many as eight patients.
A report released by the coroner's office on Monday includes 25 recommendations on ways to improve the not-for-profit air ambulance system.
A panel of experts who reviewed 40 cases found that operational problems at Ornge had a possible impact in five deaths, a probable impact in one, and a definite impact in two.
The panel reviewed cases from January 2006 to June 2012.
In one case, it the panel found it was probable that operational issues played a role in the death of the 50-year-old man who was critically ill and died of bilateral lobar pneumonia.
The man was initially driven by ambulance to a remote community centre where he was stabilized but required transfer to a major hospital for further treatment, the report said.
"There were difficulties on the transfer flight with compatibility between the aircraft and the paramedic equipment (namely the oxygen tubing for the transport ventilator) which required the patient to be manually ventilated," the report said.
"Additionally, there were communication and logistical issues in coordinating the land ambulance to meet the fixed-wing aircraft for transfer to hospital which added a delay of approximately 30 minutes."
The review was launched last August by then chief coroner Dr. Andrew McCallum after the release of cabinet documents that showed the government investigated 26 deaths involving its troubled air ambulance service since 2007.
The deaths related to 145 incidents involving Ornge that were investigated by the Ministry of Health.
McCallum left the position at the coroner's office in late January to become president and CEO of Ornge.
Ornge improves processes
Ornge responded to the report by saying "considerable progress" has been made in response processes and equipment have been made.
A number of the panel's recommendations have already been implemented or in the process of being put in place, said McCallum.
"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 in a release in which he thanked the panel for their work.
"The recommendations from the expert panel will build upon this work," he said.
Source: http://www.cbc.ca
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