Exclusive – Ministry of Health Admits There Was A “Preventable Delay” In Responding To VSA

Pete Fisher
6 years ago
• Categories: Editor Choice, Local

The Ministry of Health and Long Term care has admitted there was a “preventable delay” responding to a patient who was vital signs absent and later died.
Marian Leahy’s life changed forever when she was informed that her oldest of three children died in Cobourg.

Leahy contacted Today’s Northumberland to help find out what possibly went wrong and to warn others of the problem.

Kevin Bryant was 37-years-old when he died at a east end apartment building (330 King Street East) in Cobourg in what the coroner deemed as “accidental” citing the main cause of death as “combined drug toxicity (Fentanyl, Gabapentin and Ethanol).”
Leahy said her son had been in and out of prison for several years.

Bryant had a history of drug and alcohol abuse and had apparently consumed a bottle of alcohol earlier in the day.
“He had a good heart, but had his demons,” said Leahy.

“It’s not fair that this had to happen. If it was my own mother or father and this happened I’d be doing the same thing.”
A mothers instinct had to follow-up. What Leahy found out shocked her and she still has questions that have gone unanswered.

Leahy heard rumours it took paramedics a long time to show up, and that was multiplied when she talked with a Cobourg Police officer, who asked if Leahy was going to sue.
The coroner’s report indicated he had just recently been discharged from prison and some of the people in the apartment were “known to police for involvement with illicit drugs.”
Police indicated they found no drugs and only two possible alcoholic drinks, “with the possibility that the attendees had removed materials from the scene,” stated the coroner’s report.
The occupants of the apartment told emergency services Bryant, “had suddenly collapsed.”

Residents of the apartment told a dispatcher at the Centre Ambulance Communications Centre in Lindsay they performed CPR for 15-minutes prior to calling 9-1-1.
Because of the level of emergency (Code 4), Cobourg Police and Cobourg Fire Department were also dispatched to the scene.

A report from the Cobourg Fire Department indicated the call came from CACC (who dispatch for Northumberland County Paramedics) in to Peterborough Fire Department (who dispatches for Northumberland County Fire Departments) at 12:27:50 a.m. on August 11, 2017. Firefighters responded at 12:28:44 (1 minute and 34 seconds from receiving the call) and arriving on scene six minutes later.
Firefighters found Bryant on the kitchen floor with one person “attempting chest compressions” states their report.

Firefighters quickly started CPR and attached the AED (Automated External Defibrillator) which would indicate if a“shock” is required. Three times firefighters analysed the patient, but each time “no shock” was indicated. (Cobourg Fire Department started carrying Narcan in the Fall of 2018).

Cobourg Police received a call to a location in the west end of Cobourg regarding a person with vital signs absent at 12:22 a.m.
At 12:27 a.m., “police arrived on scene and were advised that there was a miscommunication as two 9-1-1 calls came in and the actual address was 330 King Street East Cobourg.”
At 12:35 a.m. police arrived on scene to find firefighters already on scene with the patient still vital signs absent. (13-minutes after receiving the call)

With the initial 9-1-1 call coming in at 12:18 a.m. paramedics arrived at the patient at 12:43 a.m. (approximately 25-minutes after the first 9-1-1 call was reported).
Leahy might have been able to accept that, but when she got the audio of the 9-1-1 call from CACC the dispatcher said paramedics were just around the corner from the address.

At 12:26 a.m. a caller said to CACC, “I think he’s gone.”

“Do you know how close they are?” states the caller.

“Just a moment,” replies dispatch.

“Ok, they are just around the corner – they shouldn’t be long. I’m going to let you go,” states ambulance dispatch.

But at 12:34 a.m. the same woman calls CACC once again.

“What is your emergency?” states CACC .

“I just called for an ambulance and they are not hear yet,” states the female caller.

After the address is given, CACC states, “how’s the patient doing?”

“He’s like gone almost,” states the caller.

“What do you mean almost?” states CACC.

“Like f–k, where are you people?” a voice shouts in the background from the apartment.

“We just got inundated with emergency calls in Cobourg,” states CACC.

“We’re going as fast as we can ok?.” states CACC aggressively.

“Well this guy is like dead on the f–king floor,” states the woman.

“They’re just around the corner,” states CACC.

“You said that last time.” states the caller.

“Well they’re not that far away ma’am.” states dispatch.

“Well please hurry, this is ridiculous,” states the woman.

Ambulance dispatch tells the woman to continue doing CPR and the line goes dead. It’s not clear whether the caller hung up or dispatch did.
At 12:41 a.m. paramedics arrived on scene and at 12:43 a.m. they arrive at the patient.
From the start Leahy has had a hard time getting accurate information.

Ministry of Long Term Care said she would have to be the trustee in her son’s will, but her son didn’t have a will.
With the help of a lawyer, Leahy slowly got information over months and then years.
“Could it have been prevented if they’d got there early?”
“I can’t close off how I’m feeling until I know what really happened.”

In one report it states, “We (paramedics) were original dispatched to an MVC (motor vehicle collision) on the 401 which after (another ambulance) was sent to the wrong call in Cobourg, we were put on the Code 4.”

The first 9-1-1 call came in to emergency services at 12:18:58 a.m. on August 17, 2017 it took just over one hour of time that had elapsed by the time emergency services travelled just under five kilometres to arrive at Northumberland Hills Hospital triage at 1:20:00 a.m. with Kevin Bryant.

Even the people who called 9-1-1 stated he had been doing CPR for 15 minutes.
“Why did it take so long to call?”
There were numerous people in the apartment, “so why couldn’t they have called?”
Leahy said she is grateful for the emergency services efforts, “but I want to know what happened to the first bus (ambulance) that was called.”
“Why didn’t it show up.”
“It might have been able to save my son’s life?”

In a report police admitted they went to the wrong address, but how did that happen?
“I want the public to know that the people have to do their job right.”

Leahy still holds out hope to find out what happened and in late March 2019 she got a completed report after an investigation by the Ministry of Health and Long Term Care.
The 17-page document by the Emergency Health Regulatory and Accountability Branch, Investigation Services Unit found a number of actionable items including:

· the dispatcher did not obtain accurate information for the two emergency calls.

· the dispatcher did not provide the proper Cardio Pulmonary Resuscitation Instructions.

· the dispatcher terminated the VSA call before the arrival of the first responders or paramedics.

· the dispatcher did not create a new call for the second call back for the VSA patient or asking the required questions.

A number of observations were also learned in the investigation including:

· there was an approximate seven minute delay in the commitment of the Code 4 (Urgent) VSA patient to the dispatcher for assignment.

· from the time the VSA call was first received until an ambulance arrived on scene, approximately 22 minutes had elapsed.

· CPR instructions provided to the caller did not meet the compression requirements.

· the evidence supports CACC had an influx of requests for emergency ambulance service in the Cobourg area in a short period of time.

· four emergency call requests were received within four minutes, taxed the ACO’s (dispatchers) time management; however the CACC provides directions and process to address increased emergency call volumes.

· even though the CACC dispatcher told the caller during the second 9-1-1 call the ambulance was just around the corner, the investigation revealed the ambulance was still approximately seven minutes from arriving.

The investigation summary concluded, “there was a preventable delay in the response of an ambulance to a VSA patient, caused by the actions of an Ambulance Communications Officer. The error could also be attributed, in part to the technical process of the Computer Aided Dispatch (CAD) system.”

Though Leahy now has answers from the Ministry of Health and Long Term Care she still doesn’t know why police initially went to the wrong address.

“Knowing the services (police and paramedics) didn’t do what they should have done makes it even tougher.”
“It’s the not knowing. Could my son be alive if they showed up or would he still have passed?”
“I need the closure.”