The New Brunswick Department of Health has released an independent report Thursday that found a series of flaws in the province's ambulance system, including no clear policy on maps, training and dispatching.
Health Minister Michael Murphy tabled the report, written by Richard Brady, a senior Ontario Health Department official, which stemmed from the case of 14-year-old Cody Jones.
Jones died on April 2 after it took 57 minutes for a second ambulance to get to his Fredericton Junction home after the original emergency vehicle went down a road closed due to flooding and got stuck on a different back road.
"My department commissioned this report to bring to light any service deficiencies and weaknesses that led to this delay so that they may be corrected," said Murphy in a statement.
"Mr. Brady has provided a thorough review of what deficiencies in the system contributed to this delay and has made recommendations for improvements that could help ensure similar incidents do not occur."
Brady report conveys drama
The Brady report is dry and technical, but still conveys some of the anxiety surrounding events on the night of Jones's death.
The 911 call came as the 14-year-old boy was having trouble breathing at his home in Fredericton Junction.
A paramedic co-ordinator, who is identified only as 4620 in the report, told the investigator that he heard the stress in the first crew's voice as they encountered two road closures on the way to the home.
The co-ordinator said the second ambulance should have been dispatched sooner.
But as the report points out, Ambulance New Brunswick had no clear policy on what to do about a delay or even how to define a delay.
Co-ordinator 4620 also said outside paramedics who have to respond to calls in the area had no way of knowing about local road closures.
Two other paramedics who are posted to the area but who weren't working that night told the investigator that they know when to avoid certain roads but Ambulance New Brunswick never asked for their input.
Several problems led to delay
The Brady report identified a series of problems that caused the delay in navigating to the Fredericton Junction house:
- A shortage of maps and training.
- Poor information on the status of local road closures.
- Lack of dispatch and fleet policies.
- Lack of paramedic-dispatch communications policy.
Murphy said the provincial government and Ambulance New Brunswick are already addressing some of the problems identified in the Brady report, including by hiring 90 new paramedics to close coverage gaps.
Other measures include altering paramedic shift changes to avoid gaps in coverage of an area and designing an ambulance deployment plan to make sure there is a better allocation of ambulances around areas such as Fredericton Junction.
A complete copy of the report is not yet available, but the Health Department said it will be posted on the government website once it is translated.
