Ombudsman calls for overhaul of Ontario’s ‘unreasonable and wrong’ process for handling ambulance-related complaints (QP Briefing)

Ombudsman calls for overhaul of Ontario’s ‘unreasonable and wrong’ process for handling ambulance-related complaints (QP Briefing)

May 20, 2021

20 May 2021

Ontario's Ombudsman has released a highly critical report on the province's investigation of complaints concerning ambulance services, finding ministry inspectors act as "rule trolls" that penalize technical rule violations of little-to-no consequence while ignoring other potentially life-threatening problems as outside of their scope.

By Jessica Smith Cross
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May 20, 2021

Ontario's Ombudsman has released a highly critical report on the province's investigation of complaints concerning ambulance services, finding ministry inspectors act as "rule trolls" that penalize technical rule violations of little-to-no consequence while ignoring other potentially life-threatening problems as outside of their scope.
 
"Oversight 911" details a neglected and underfunded corner of the Ontario Public Service, broken by high management turnover, that spends a great deal of time shuffling pieces of paper the Ombudsman deemed are mostly useless. Some of the report's details about administrative failures would be laughable, if that corner of the government wasn't responsible for ensuring standards in life-saving medical care.

Ombudsman Paul Dubé called for a complete overhaul of the process of how the Ministry of Health handles complaints concerning the $1.5-billion emergency medical services system.

"Emergency ambulance service is a fundamental part of our health-care system and can mean the difference between life and death," he wrote in the report, which was ready for release a year ago but awaited a response from the ministry, which was delayed by the pandemic until now.

The ministry has committed to implementing the report's recommendations.

Dubé said his office had handled relatively few complaints concerning ambulance services over the years but had noted issues with the ministry's investigative process, and it was a whistleblower who sparked his broader review, launched in 2018.

The insider told the Ombudsman that "things were pretty much in chaos and that this really deserved to be looked at," Dubé told QP Briefing, adding that the whistleblower's complaints were borne out by the investigation.

His office uncovered serious issues with how the Ministry of Health handles complaints concerning the $1.5-billion emergency medical services system.
 
"Ministry investigators conceive of their role and mandate as being very limited, which means that many complaints about ambulance services are not investigated," he wrote. "When the ministry does investigate, we found that investigators operate with almost no policies or procedures to guide their investigation or decision-making process, and there are often long delays before investigative reports are released.

"The reports themselves are difficult to understand, without clear recommendations to fix identified issues. Even worse, the ministry does almost nothing to follow up on investigation findings to ensure that problems are actually addressed so that they do not recur. We found that a lack of training, high levels of staff turnover and understaffing within the unit exacerbated each of these issues."

Patients who do have complaints will find it hard to understand where to direct them, he noted, in part because the responsibility for investigating them and acting on them is split between complaints that consist of violations of the Ambulance Act, which the ministry considers itself responsible for, and complaints about other problems that fall to the emergency medical service providers in question.

As a result, the ministry won't investigate issues like customer service-style complaints like rude behaviour or mistreatment by paramedics, even if the result is a delayed arrival at a hospital. In one case he explored, it meant the ministry declined to investigate a potential drug overdose by a paramedic that could have had fatal consequences, deeming medication errors a violation of the EMS provider's policy and its responsibility.

However, the ministry will investigate more meaningless issues. For example, paramedics are required to carry every patient to a stretcher and will be found in violation of the Act, even if the patient was able to walk and did not want to be carried, he found.

"One described this as an example of ministry investigators acting as 'rule trolls,' preoccupied with the letter of the law and not allowing for nuance," he wrote.

In his report, Dubé finds that's too narrow a scope for the ministry, which has a legislative duty to set standards for ambulance services and ensure compliance with them.

And complainants that do find their way to the ministry don't have an easy task, he found.

"Complainants are given little to no information, leaving them with only a hazy idea of what will be investigated or the process for doing so. At times, investigators don’t even contact complainants to get details about their concerns or to provide a copy of the final investigative report," he wrote.

"My investigation concluded that the Ministry of Health’s administrative process for investigating and overseeing patient complaints and incident reports about ambulance services is unreasonable and wrong under the Ombudsman Act."

Alarmingly, there were no set processes for investigations and minimal training, the report found. The investigations themselves rarely involved interviews with complaints and witnesses, with the investigators dismissing witnesses with any connection to the complainants or paramedics involved as biased and declining to dive into complaints of a “he said/she said” nature.

"You have to have a robust investigative process that conforms to best practices and basic standards like interviewing people," Dubé told QP Briefing. "You know, when you say, 'Yeah, we had an investigation but we didn't interview people,' I call that a paper review and that's not an investigation."

Also alarming was the management of the unit.

The report said the Investigative Services Unit has been plagued by high staff turnover and vacancies and as a result improvements to its processes weren't made.

The information management protocols described in the report are a nightmare: "We were told that at one time, investigators were given special notebooks for each investigation file, in which they documented their work by hand. When an investigation was completed, the notebook was scanned and stored on a shared drive with other investigation documents. However, in early 2018 these notebooks ran out and the ministry determined they were too costly to reorder. Nothing was ever developed to replace these notebooks. If the ministry is to meet the public’s expectations of 21st-century investigations to ensure proper oversight, it will have to evolve from 19th-century tools."

The report details the practice of “incident reports,” which EMS providers, dispatch centres and Ornge are required prepare and send to ministry field offices in response to many circumstances, leading to 250,000 such reports a year. The idea is that they will alert the ministry to issues that require further review.

"But my investigation found that they are largely a meaningless paperwork exercise that fails to increase oversight or accountability," Dubé said.

The problems with the reports are endless: they are duplicative, vague, late, handled by people with no knowledge of what they are supposed to be documenting, and in the words of one EMS provider, “they just go to the abyss.” Finding the important reports among the routine is like "having to find Waldo," according to a senior ministry official.

Asked to explain why things were allowed to get so bad, Dubé said he believes it was "neglect."

"One thing that's a constant, whether it's at the federal level or provincial level, when I'm doing a deep dive into a government program or service, is we don't find things that nobody's aware of, that the organizations are not aware of," he said. "When you talk to the people involved they say, 'I wanted to fix this for a long time, but there are only so many resources to go around.' When you sit at a table and you say, 'I need this,' sometimes you win, sometimes you lose."

"This whole Investigative Services Unit within the Ministry of Health was just a neglected child for a long time," he added.

A brief response from the ministry is included in the report, saying that the ministry has accepted each of the 53 recommendations and is already working on 16 of them, "including those related to investigation protocols, followup processes, and investigator orientation and training," and will report back to the Ombudsman on the progress.

Dubé said that improving the Investigative Services Unit will improve EMS care for Ontarians.

"The potential is always huge. We're talking about matters of life and death," he said. "This is about bolstering a system of oversight that ensures that the system works properly."


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