A coroner's jury has called for changes to the design of B.C. ambulances following the death of man who fell out of an emergency vehicle and died in Quesnel last year.

Ebony Aaron Wood, 36, was being transported to hospital in Quesnel after a motor vehicle accident when he fell out of the ambulance, suffering blunt force trauma. He died two days later.

Wood was in police custody at the time.

Following a three-day coroner's inquest this week, a jury made six recommendations to BC Ambulance Services and two to RCMP on how to prevent similar deaths in the future.

BC Ambuland at Surrey school

The proposed changes include the addition of GPS technology and improved rear door locks to ambulances. (Shane MacKichan)

Recommendations to the BC Ambulance Service include:

  • Implement changes to ambulance design that allow for two-way communication between paramedics.
  • Routine check and inspection of ambulances should include the features of the vehicle that are operational while the vehicle is in motion; this would require completing checks while the vehicle is in motion.
  • Add visual indicators to the ambulance that inform both the driver and the attending paramedic that all vehicle doors are closed and locked.
  • Upgrade the GPS technology available to paramedics to allow for different directional orientation of the mapping information.
  • Implement changes to rear door lock location, so as to limit patient's access to the locking door mechanism.

One recommendation is for both the RCMP and the BC Ambulance Service:

  • Enhance mental health and substance use training provided to first responders that improves their ability to assess behavioural indicators of risk.

A final recommendation was given to the RCMP:

  • Ensure any behavioural issues that could endanger the patient or others are communication to the BCAS when care is transferred.

The death was ruled as accidental. 

'This was a sad and devastating loss' - Linda Lupini

BC Emergency Health Services executive vice president Linda Lupini said her organization is reviewing the recommendations while waiting on a final report from the Coroners Service.

"Our hearts go out to [Wood's] family and friends," she said in a statement.

"This was a sad and devastating loss."

Regional coroner Donita Kuzma presided over the inquest and is expected to prepare a final report providing more details on Wood's death.

A spokesperson for the service said it was unable to predict when the report might be delivered.