The father of a woman who died on a STARS air ambulance flight says the Manitoba government is making a mistake by putting the suspended air ambulance service back in the air.
Mike Fitzpatrick's 39-year-old daughter, Kristen Joiner, died after being transported from Steinbach on a STARS helicopter flight to Winnipeg on Nov. 28, 2013. She was suffering from a pulmonary embolism and was in shock, when there were problems with an oxygen tank.
STARS was grounded in December after that and an a number of other critical incidents, including one in which a patient was left brain damaged.
As expected, the Manitoba government announced Friday STARS will resume service immediately. Health Minister Erin Selby said all medical concerns have been addressed and training has been improved. Selby also announced a new Clinical Oversight Panel has been formed, under the leadership of Dr. Brian Postl.
"The focus of the panel will be on patient safety, quality of service and reassuring public confidence in an integral component of acute emergency medical care to Manitobans," said Postl.
Selby said STARS, a non-profit organization, has agreed to new measures to enhance safety.
"We left it to our medical professionals to guide us back up into the air," she said. "We trust and value their opinion. We respect their experience and when they tell us their concerns have been addressed, that we are ready to go up for emergency calls, we respect that opinion."
STARS CEO Andrea Robertson added medical personnel and staff have received intensive training while the service was grounded.
"The Manitoba crew has spent a great deal of time at other high-flying bases, more active bases," she said. "We have gone through very detailed analysis of their competencies. There has been many changes made."
The air ambulance service will now be under the jurisdiction of the Winnipeg Regional Health Authority, instead of Manitoba Health.
But Fitzpatrick said he still has questions about patient safety during STARS flights.
“Their main concern is that this doesn't happen again? Then they're just going to put them back in the air? It could very well happen again," he said.
Fitzpatrick was provided the results of a critical incident report Thursday into his daughter’s death. Manitoba Health officials told him paramedics on board the STARS transport grabbed a depleted portable oxygen tank, even though a full one was sitting right next to it.
He said the incident review found the depleted tank ran out, and his daughter was given medications instead of being hooked up to the other tank. The medical examiner found that she would have died anyway, but Fitzpatrick says he doesn’t know how they can be sure.
Fitzpatrick was also angry because Manitoba Health told him Thursday they didn’t know when STARS would be back in the air, which was confirmed today.
STARS denied allegations
In an earlier interview with CBC News, STARS denied they ever ran out of oxygen. They said the portable tank on board Joiner’s flight was “running low”.
"She never went without adequate medical oxygenation.” said Dr J.N. Armstrong, chief medical officer of STARS, adding the oxygen tank "was identified, and the cylinder was changed out.”
After Joiner's death on November 28, 2013, Health Minister Erin Selby announced she had instructed her department to suspend all STARS flights.
“The response, the taking the base of service response was based on the concern about the O2 cylinder running out when in fact it was just low,” Armstrong told CBC. “It was an initial I think, misunderstanding of the circumstance.”
Draft report slammed STARS
Dr. Stephen Wheeler, medical director of B.C. Air Ambulance and Critical Care Transport, was hired by the province to review STARS. In his draft report, obtained by CBC News, he slammed the Shock Trauma Air Rescue Society in the report, citing the goal “to identify any underlying systemic issues” and to make recommendations to improve patient management services
Wheeler’s report says “running out of oxygen should never happen," and "all air transfer organizations go to great lengths to ensure this does not occur, as the consequences can be catastrophic."
Wheeler said Manitoba’s STARS air ambulance crews lack adequate training, are not familiar with pediatric patients and do not understand patient oxygen needs.
“As a group, the nurses and paramedics lack adequate training and experience to work in the air medical environment,” Wheeler writes in his report.
“Compared to other air medical transport programs across the country, its training program is remarkably brief and cannot provide the necessary amount of training required for modern, complex, critical-care transports.”
Here are the recommendations contained in Wheeler’s draft report, dated Dec. 23, 2013.
- STARS should redesign its training program and certification process for its crews in line with other Canadian provinces and immediately supplement its crews with experienced flight personnel for a minimum of six months.
- STARS should review its pediatric training with an emphasis on airway assessment and management.
- STARS should be limited to transporting pediatric patients only in trauma scene responses.
- STARS should have on board medical personnel from Children’s hospital for all pediatric inter-facility transfers.
- STARS Manitoba and Manitoba dispatch Centre should establish a pediatric medical oversight model for triaging and dispatching pediatric patients.
- Further intensive training of STARS crews in advanced airway management should be done immediately.
- Video laryngoscopy should be included in STARS skill set for crews.
- Until STARS has well-trained crews, physicians should be onboard all missions with airway and ventilation issues.
- STARS should limit its transport of pediatric patients to trauma scene responses, and not carry out routine patient transfers between facilities, while it reviews its pediatric training. Emphasis should be on pediatric airway assessment and management.
- STARS should review its physician orientation process to increase the understanding of the advantages of different transport modalities.
- STARS orientation should include a set number of fly-alongs with crews.
- A dedicated, local Quality Improvement director should be established.
- STARS should express its commitment to be a quality organization and back up its commitment with action and accountability.
- STARS should develop a Crew Resource Management culture.
- All dispatching of air medical transports should go through central provincial dispatchers who will determine the most appropriate mode of transport.
- The patient should go by the faster means possible.
- A feasibility and cost analysis of building hospital helipads should be done for all Southern Manitoba hospitals.
- A comprehensive maintenance of competencies program should be established and monitored for STARS crews.
- STARS crews should be rotated through more high volume programs including other STARS bases and Manitoba Lifeflight.
- Quality control must improve because “overall, an emphasis on creating and maintaining a culture of quality is missing.”
Read the final assessment report on STARS released Friday below.