A 55-year-old man in Northern Ontario waited nearly five hours for an air ambulance to transport him to a hospital in the south after he suffered a seizure.
Another patient's supply of oxygen ran out before an air ambulance transporting him from the north arrived at a hospital in eastern Ontario.
Their deaths are among eight in which operational problems at Ornge played a role, according to a report released by the province's chief coroner on Monday. Two of the deaths – including that of the 22-year-old man whose oxygen flow rate was mistakenly set too high, causing it to run out just before the air ambulance landed – were directly linked to the problems.
The coroner's office examined 40 cases in which patients died after a request for an air ambulance. For one in five patients, shortages of key paramedic staff at Ornge, communications breakdowns and slow response times are among the problems that contributed to their deaths.
In a news conference at Ornge's head office west of Toronto, chief executive officer Andrew McCallum apologized for the deaths.
"One preventable death is too many from my perspective," Dr. McCallum said.
Opposition members said the chief coroner's report confirms what front-line staff at Ornge have long suspected: the financial mismanagement of the air ambulance service and a shortage of pilots and paramedics compromised patient care.
"Witness after witness testified that wrong-headed management decisions and incompetence were directly responsible for putting patients at risk," Progressive Conservative MPP Frank Klees said.
The Ontario government provides Ornge with annual funding of $150-million to manage all aspects of the province's air ambulance service. Ornge has spent the past 18 months embroiled in controversy over private, for-profit ventures created by former insiders that are now at the centre of an Ontario Provincial Police probe.
The coroner's office examined cases over a 7.5 year period, beginning with the creation of Ornge in January, 2006. The report comes a month after one of Ornge's helicopters crashed on the James Bay coast of Northern Ontario. No patients were on board, but all four crew members perished in Canada's first fatality involving a helicopter air ambulance.
The coroner's office acknowledges that it may not have captured all deaths in which Ornge's operations played a role.
"This is a really tough day for a lot of families," Health Minister Deb Matthews said in an interview, explaining that some people felt the deaths of their loved ones should have been in the report.
Three of the deaths the coroner examined involved a design flaw associated with the interior of Ornge's new air ambulance helicopters. The pedestal for the stretcher was too high, restricting paramedics from performing life-saving CPR on patients. The coroner's report says the height of the pedestal did not contribute to the deaths of the three patients. Nevertheless, it says, the problem needs to be addressed.
Dr. McCallum ordered the review of patient deaths when he was the province's chief coroner. He was appointed to lead Ornge in January, and said the agency has addressed most of the deficiencies cited in the report, including beefing up training for dispatchers, minimizing the number of call-takers handling an emergency, and modifying the interior of the helicopters.
Dr. McCallum also hinted that financial settlements may be forthcoming. "We want to be fair and equitable to the families."