Lack of training, tools contributed to slow response time, death of teen

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By Nick Moore
Times & Transcript Staff

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FREDERICTON - No one can say whether a faster ambulance on April 2 would have saved the life of 14-year-old Cody Jones.

The boy was suffering from a breathing emergency and died before an ambulance reached his home in Fredericton Junction.

But the fact it took 57 minutes and nine seconds for an ambulance to show up for the emergency call is completely unacceptable, and could have been prevented, an independent report has concluded.

"Inadequate training, a lack of clear policies and procedures and a lack of the right resources and tools available to the paramedic and dispatch staff combined to create a situation where a patient needlessly suffered," Don Brady said in an independent report about the incident released yesterday.

Brady, who is the investigation unit manager for Ontario's Ministry of Health and Long-Term Care, was asked by the New Brunswick government to investigate the incident, in which two ambulances were dispatched.

The first ambulance turned down two closed roads that were blocked by flooding before a second ambulance was dispatched. Jones went into cardiac arrest about 25 minutes after the emergency call was first made by his sister.

By the time the second ambulance arrived at the Fredericton Junction residence about 24 minutes after it was dispatched, Jones had no vital signs and efforts to resuscitate him were unsuccessful.

The flooded roads were listed as closed on the government's road advisory list but that information didn't get to ambulance staff, Brady noted.

In his report, Brady recommended that ambulances should have the most up-to-date mapping resources available, adding that paramedics and dispatchers should develop protocols where they're aware of all road closures or other geographical changes on potential routes.

In that same light, the report said Ambulance New Brunswick should review and strengthen geographical training for paramedics and dispatch staff concerning the areas they're responsible for.

Brady's report also recommended that Ambulance New Brunswick and the Department of Health review all decision-making processes when it comes to juggling emergency and non-emergency response calls (which would include non-emergency hospital transfers).

In the case of Cody Jones, the ambulance which should have been providing emergency coverage to the Fredericton Junction area on April 2 had been assigned to a non-emergency transfer from Saint John to Fredericton.

"We do way too many transfers compared to 911 calls," said Ralph McBride, co-ordinator for paramedics' union CUPE Local 4848, who was responding to the independent report yesterday. McBride said recommendations made in the report are things he's been saying for awhile.

"It's very unfortunate that there had to have a tragedy in Fredericton Junction for the government to finally listen," he said. "It's good that they are listening now."

McBride is pushing for 'transfer only' ambulances to be put in place as soon as possible.

"In rural New Brunswick there are major gaps," McBride said, adding that non-emergency transfers usually come at the expense of ambulance coverage in rural areas because the vehicles leave smaller communities to pick up patients from hospitals and health facilities in larger centres.

Health Minister Mike Murphy said his government is pleased with the recommendations in Brady's report.

"We'll ensure that all the recommendations of the Brady report are put in place, and many of them are already, but we will make sure everything is in place," he said.

Murphy said under Ambulance New Brunswick's own case review, adjustments have been made to keep more detailed and updated maps in vehicles, while also making sure shift changes are carried out seamlessly. The hiring of 90 new paramedics, to be on the job by July, is also being carried out throughout the province.

As well, bilingual computer software is being developed that will provide updated maps in ambulances.

Progressive Conservative MLA Jack Carr also applauded the report, but wanted to see another independent review of Ambulance NB in six months to ensure every recommendation had been followed up. Carr is also requesting another report in one year's time to review the entire system.

"I think New Brunswickers need to be better reassured that this will never happen again," he said. "New Brunswickers' confidence needs to be restored."

Murphy was non-committal about additional reports.

"We'll see how the next several months go," he said. "We may be very well satisfied within a short time that all the recommendations are in place and things are much better. But you can never rule anything in or out."

Ambulance New Brunswick confirmed they received a copy of the report yesterday, but said they would be withholding any comment until later this morning.

Tragic Timeline

Included in Brady's independent report is a heartbreaking minute-by-minute account of what happened over the close to one-hour period it took for an ambulance to respond to an emergency call made from Fredericton Junction on April 2.

The 90th percentile response time for a standard Code 1 (life threatening) ambulance call is 22 minutes for rural areas.

The 90th percentile response time standard says that nine times out of 10 an ambulance should be on the scene within 22 minutes.

On April 2, it took 57 minutes and nine seconds for an ambulance to arrive on the scene for 14-year-old Cody Jones, who was suffering a breathing emergency.

* 6:19:43 p.m.

- An emergency call was received from a young woman indicating that her 14-year-old brother was suffering from severe difficulty breathing.

The ambulance that normally would have been in Fredericton Junction was completing a non-emergency transfer from Saint John to Fredericton.

An ambulance stationed out of Oromocto (about 30 kilometres or 20 miles from Fredericton Junction) was providing coverage over the Fredericton Junction area during that time.

* 6:20:02 p.m.

- The Oromocto ambulance was assigned to respond to the incident, which was classified as a Code 1 call (or a life-threatening ambulance call).

* 6:37:01 p.m.

- The ambulance dispatched to respond to the Fredericton Junction emergency informed the dispatcher that the road they were using to get to the residence was blocked off.

The ambulance said they would have to backtrack in order to find another route.

* 6:45:08 p.m.

- The ambulance was informed that their patient was in cardiac arrest.

* 6:52:35 p.m.

- The ambulance dispatched to respond to the Fredericton Junction emergency reported back to the dispatcher that they had taken another road and that it was also blocked off.

The ambulance said they would be unable to proceed to the emergency call in Fredericton Junction.

* 6:53:10 p.m.

- A second ambulance, the night shift ambulance stationed in Oromocto, was assigned to the emergency call in Fredericton Junction.

* 7:16:52 p.m.

- The Oromocto night shift ambulance arrived at the Fredericton Junction residence and reported the patient had no vital signs.

Paramedics were not able to resuscitate the patient.