Report reveals details of death on Ornge helicopter

CBC News in Thunder Bay has obtained a report on the 2006 death of a First Nations woman on an air ambulance, after being told it did not exist.

Delayed response time, poor phone service ‘had some bearing’

A report obtained by CBC News in Thunder Bay says the satellite phone on the Ornge aircraft was “not functional” and medics were unable to contact the hospital, or the doctor overseeing the patient's treatment until about 10 minutes before they landed in Sioux Lookout. (Nil Koksal/CBC)

CBC News in Thunder Bay has obtained a report on the 2006 death of a First Nations woman on an air ambulance, after being told it didn’t exist.

The report answers some of the questions First Nations leaders have been asking for years.

Sheila Childsforever was picked up by Ornge helicopter at Wawakapewin First Nation on Dec. 7, 2006. The tiny village doesn’t have a road or an air strip.

An initial coroner’s report noted that a delay in Ornge response time and the care available on board the air ambulance "had some bearing" on Childsforever’s death.

The Nishnawbe Aski Nation (NAN) wanted an inquest into her death, but its request to the coroner was denied.

‘Significant deterioration in flight’

"We had hoped to try to raise the issue of Ornge and the service they’re able to provide fly-in communities," then-NAN Grand Chief Stan Beardy told CBC earlier this year. "They’re dealing with, in many cases, life and death, so the response has to be there."

In 2007, Ornge told the First Nation organization that it wrote a report about Childsforever’s death. The letter said chiefs could ask the coroner’s office for a copy. NAN was unable to obtain it.  In February 2012, a spokesperson for the coroner’s office denied to CBC that such a report existed.

CBC News obtained the Ornge complaint/incident review summary through freedom of information.  It was completed on December 11, 2006.

The report says Childsforever was "alert" and "oriented to person, place, but not time" when greeted by paramedics shortly after 2 p.m.  She experienced "significant deterioration in flight" and by 4:30 p.m. medics were initiating CPR. 

Phones ‘not functional’

After a fuel stop in Pickle Lake, the Ornge helicopter landed at Sioux Lookout Airport at 4:46 p.m. and Childsforever was taken by land ambulance to the hospital, arriving at 4:58 p.m.

"Medics stayed on scene for the duration of the resuscitation", the report says.  By 5:35 p.m., Childsforever was declared dead.

The report says the satellite phone on the plane was "not functional" and medics were unable to contact the hospital, or the doctor overseeing the treatment until about 10 minutes before they landed in Sioux Lookout.

One crew member suggests cell phones would be more reliable than satellite phones for Ornge planes.

A spokesperson for Ornge said they looked into that suggestion and determined that an upgraded satellite phone system was the answer.

"Satellite phones are the preferred option for this working environment.  The reliability has increased significantly since we made this upgrade," Ornge media relations officer James McDonald wrote in an email to CBC.

No air strip

The report also notes the length of time it took to get Childsforever to hospital. The use of a fixed-wing air ambulance may have cut that time because it would have had to make fewer stops for fuel. But with no air strip at Wawakapewin, there is  no place for a fixed-wing plane to land. The Ornge helicopter needed to stop for fuel on its way to pick Childsforever up, and on its way to hospital.

"One option that may or may not have been possible would have been to transport the patient by land to another community in the north that did have an airstrip for fixed wing transport," the report says. "The logistics of this however may have been impossible, particularly for a very sick, unstable patient."

Ornge declined comment on Childsforever’s case specifically, citing patient confidentially.

"On occasion, depending on patient condition and resource availability, Ornge will engage local services – such as EMS – to transport patients by land to the closest airport or airstrip when possible," McDonald said.  "Ornge does not control where airstrips or heliports are built as these are the responsibility of local stakeholders."