Ontario ombudsman André Marin slammed the medical community and the Ministry of Transportation for failing to report drivers who have uncontrolled hypoglycemia, a condition Marin says is as dangerous as impaired driving and remains a open threat on Ontario's roads and highways.

The comments come after the ombudsman conducted a probe into why the Ministry of Transportation took 18 months to suspend the licence of a man who killed three people while driving with dangerously low blood sugar. In his report he called the system "broken" and a “bureaucratic farce.”

But in the comments that followed, he said doctors have "failed" in their duty to report drivers with uncontrolled hypoglycemia, which affects a quarter of the more than 7,300 insulin-dependant Ontario drivers.

"Right now, what is happening in Ontario is bureaucratic calamity mired by general chaos," Marin said.

Hamilton high school teacher Allan Maki was tried and convicted of dangerous driving causing death in a triple-fatal car crash in 2009, which killed an 81-year-old cyclist and a pair of newlyweds when he went into diabetic shock.

READ MORE: Hypoglycemic driving a concern, Ontario watchdog says

Marin’s investigation revealed that even though paramedics found his blood sugar to be dangerously low at the scene of the crash, multiple bureaucratic breakdowns allowed Maki to drive with a potentially dangerous medical condition for a year and half after the crash.

A 'ticking time bomb'

"In the case of Maki, the accident occurred in 2009," Marin said. "He started having episodes of uncontrolled hypoglycemia as early as 2002. So there’s a lag of seven years.

"This is more than a time bomb ready to explode because he did explode causing the death of three people. And then after he’s arrested, charged, (the ministry didn't) pull his record, his driver’s licence for a year and a half. There’s something wrong with that system."

The ombudsman has made 19 recommendations that the Ministry of Transportation expects to implement by September. For example, he suggested the ministry should work together with the Canadian Diabetes Association to develop guidelines on driving with diabetes.

“In Mr. Maki’s case, the system clearly broke down,” Marin writes in his report “Better Safe Than Sorry.”

“The potential for catastrophic accidents involving drivers with conditions such as uncontrolled hypoglycemia might have been diminished had the Ministry been more proactive in promoting and monitoring driver safety,” Marin wrote. “It is my sincere hope that implementation of my recommendations will lead to safer driving in Ontario and prevent similar devastating incidents.”

Doctors have "failed"

Marin said while no one body should be responsible to shoulder the blame, he pointed repeatedly to doctors' duty to report their concerns to the ministry. 

"Our legislation is full of requirements on doctors to report patients in certain circumstances. It’s been here since 1968. It should be done in a much more rigorous, methodical fashion and not allowed to languish," Marin said.

"The medical community doesn’t seem to be catching on to their obligation to report back to government and the ministry sometimes gets the information and doesn’t act on it. I think that vehicles are missiles and in the hands of drivers with unaware hypoglycemia or uncontrolled hypoglycemia, those missiles are turning out to be uncontrolled and a huge danger to the public... There’s no one person or one body that should shoulder the entire responsibility, but having doctors do their duty is the first step."

As serious as impaired driving

Marin said the threat of uncontrolled or unaware hypoglycemia should be taken as seriously as drunk driving, including the ability to report the condition to police.

"I think it is as serious as impaired driving, there’s no doubt about it. People pass out at the wheel, completely pass out, turning their car into an unguided missile," Marin said.

"The government has been very effective in running campaigns against drunk driving, raising public awareness. In this case we’re counting on stakeholders, the Canadian Diabetes Association, we’re counting on the ministry to use the tools it has at its disposal to raise public awareness"

Marin stressed he believes there is a serious public threat to safety on Ontario's roads.

"Do I think today in 2014 another Maki could be out there threatening public safety? Of course I do. There’s absolutely no doubt if you view what we’ve discovered there is a serious threat to public safety," Marin said.

Responding to victim complaints

On Dec. 8, 2011, Maki, who has type 1 diabetes regulated with insulin, was convicted of three counts dangerous driving causing death and sentenced to three-years of probation and given a 10-year driving ban for the deaths of Tong Vi Duong, 81, Hannah Gordon-Roche, 27, and Jeffrey Roche, 29 for the crash on June 26, 2009.

Complaints to the ombudsman from the Gordon family as to why Maki continued to drive 18 months after the triple-fatal car crash spurred Marin’s investigation.

"For the relatives of his victims who complained to my office, this was adding insult to the 
unspeakable injury they had already suffered," Marin said. "The question had to be asked, if the system didn’t 
kick in to suspend Mr. Maki’s licence, how can we be confident that it is working to monitor 
other at-risk drivers?"

Following the crash, Hamilton Police did not submit a Driver Information/Request for Driver’s Licence review form to the Ministry that would have mentioned the condition.

However, an officer interviewed in the ombudsman’s investigation said a letter shortly after the fatal crash noting his condition was sent to the ministry on police letterhead. Also, an emergency room doctor prepared a medical condition report to the ministry.

The ministry, however, has no record of receiving either report.

A “bureaucratic farce,” report says

It wasn’t until police followed up more than a year later with the Ministry that an up-to-date assessment of Maki’s condition was requested, giving him a month to get a diabetic assessment. When he didn’t, his licence was suspended Jan. 7, 2011.

“If the reporting system had worked as intended, the emergency room doctor would have alerted the Ministry about Mr. Maki’s uncontrolled hypoglycemia,” Marin writes in the report. “The police would also have notified the Ministry about the fatal accident and Mr. Maki’s medical condition. These steps would likely have led to immediate licence suspension after review by the Medical Review Section.”

In his remarks on the report, Marin said this is where the story turns from the tragedy to a broken system.

“The story in this report is about a system that did not work as it should – the system that monitors medical conditions like Mr. Maki’s to help keep the roads safe for all Ontarians,” Marin said.

“That is where the tragic tale turns to bureaucratic farce: Even after he had caused the death of three people, the Ministry of Transportation did not suspend Mr. Maki’s licence to drive for another 18 months.”

'Hypoglycemic unawareness'

The ombudsman’s office previously said that studies show 25 per cent of people with diabetes have an inability to recognize when their blood sugar is low, a conditioned referred to as “hypoglycemic unawareness.”

It also says in 2010, there were 17,456 drivers with diabetes in Ontario, 7,336 of which are insulin dependent like Maki.

Reporting medical conditions that could affect driving has been mandatory since 1968. In 2011, the Ministry of Transportation received 723 reports for hypoglycemia.

That same year, the ministry believes 33 fatal accidents were caused by medical conditions, including hypoglycemia.