Province Should Demand Inquest After “Preventable Delay” for VSA Patient

Pete Fisher
6 years ago
• Categories: Editorial

Editorial – There is nothing that screams of a coroner’s inquest more than the case of Kevin Bryant who died on August 11, 2017 in Cobourg.
Bryant was 37-years-old when he collapsed in an apartment building just after midnight.

A 9-1-1 call was placed and although the ambulance dispatcher stated paramedics were just around the corner – they weren’t.

A second 9-1-1 call was placed several minutes later and got the same results. The dispatcher stated paramedics were very close, but in actual fact an investigation revealed they were several minutes away.
Cobourg Police were also sent to the wrong address, before being sent to the right address several minutes later.

If not for the sheer determination of Bryant’s mother, Marian Leahy none of what was found out would have surfaced.
“The ministry was contacted by the mother of a patient requesting information on an alleged delay in ambulance response to her son, who is now deceased,” states the investigation report by the Ministry of Health and Long-Term Care Report, Leahy received on March 19, 2019.
“The complainant asked why the ambulance had been cancelled, despite the fact that the caller confirmed that the patient was Vital Signs Absent (VSA).”

Leahy questioned the length of time it took for paramedics to arrive and wanted to know if her son could have been saved.
That is the answer a mother may never know.
The initial 9-1-1 call stated they had been doing CPR for 15-minutes. It’s clear by the audio there was more than one person in the apartment, so why was there a delay?

Why did Bryant not get proper medical care faster.
Leahy heard rumours about her son’s death. And the more she found out, the more she was horrified with the results.
Nearly two years after her son’s death the Ministry of Health and Long-Term Care came out with their final investigation report.
The report stated,” there was a preventable delay in 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 a technical process of the Computer Aided Dispatch (CAD) system.”
There are also a number of other “actionable items” and “observations” contained in the report.

A coroner’s inquest would have been able to come out with recommendations to prevent any such possible preventable death in the future.
To be clear, Bryant wasn’t an outstanding member of society. His mother stated he had a good heart, but he had his demons.
But what would have happened if Bryant was an outstanding, respected member of the community who received awards for public service, had buildings named after him, scholarships or was a doctor, a politician?.  Would that make a difference?  Should it make a difference?  No!

If Bryant was a affluent member of society we can all guess the probability of there being an inquest would be much greater.

Emergency service communications dispatchers are the unsung heroes that no one ever hears about in emergencies. If they are overworked and understaffed, the public needs to know. If they need more training the public needs to know.  If the system is broken the public needs to know.
Only a coroner’s inquest will or would have brought that to light.

This death may have been preventable, but even if it had not, whose to say it hasn’t happened before, or won’t happen again.
The Ministry of the Solicitor General of Ontario states a coroner’s inquest is held in part, “for the purpose of informing the public about the circumstances of a death. Although the jury’s conclusions are not binding, it is hoped that any recommendations suggested, if implemented, will prevent further deaths.”

The public should demand an inquest.

We owe it to Marian Leahy who had the fortitude to find what truth she could and to make sure there never is another “preventable delay.”