A report released on July 15 by the Office of the Chief Coroner of Ontario identifies eight cases in which operational issues at Ornge may have contributed to the deaths of patients transported by the provincial air ambulance provider.


After screening hundreds of cases of patient deaths that occurred between Jan. 1, 2006, and June 30, 2012, an expert panel struck by the Patient Safety Review Committee of the Office of the Chief Coroner identified eight cases in which 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.

The panel’s report makes 25 recommendations to improve safety within Ontario’s air ambulance transport system. Directed towards Ornge and the Ontario Ministry of Health and Long-Term Care, the recommendations cover areas such as decision-making, the response process, communication, equipment, staffing, training and quality assurance. The goal of the recommendations is to enhance Ontario’s air ambulance transport system and prevent future deaths in similar circumstances.

“It is the sincere hope of the expert panel that our efforts and the implementation of the recommendations will enhance public confidence in Ontario’s air ambulance system,” said Dr. Craig Muir, regional supervising coroner and chair, Ornge Air Ambulance Review, who was joined on the panel by Dr. Dan Cass, Dr. John Tallon and Dr. Jon Dreyer.

“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,” said Cass, interim chief coroner and chair, Patient Safety Review Committee.

In a press release, Dr. Andrew McCallum, president and CEO of Ornge, said that Ornge was “committed” to implementing the report’s recommendations.

“I want to thank the members of the Expert Panel for their thorough and thoughtful review,” stated McCallum. “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.”


The press release stated 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 stretcher does not jam during loading and unloading from helicopter; new examination and certification process for communications officers in the Operations Control Centre to improve decision making and communications; and a revised helicopter “autolaunch” policy for on-scene response to ensure aircraft launches immediately following a weather check.

Ornge will report back to the Office of the Chief Coroner in the coming months on the progress made on the recommendations.