Ombudsman recommends overhauling “complicated, overburdened” ambulance oversight system to protect patient safety

May 20, 2021

20 May 2021

Ontario Ombudsman Paul Dubé today called on the Ministry of Health to improve its processes for investigating complaints about ambulance services, in a report that reveals a system that is complicated, overburdened, and wholly inadequate.

TORONTO (May 20, 2021) – Ontario Ombudsman Paul Dubé today called on the Ministry of Health to improve its processes for investigating complaints about ambulance services, in a report that reveals a system that is complicated, overburdened, and wholly inadequate.

In the report, entitled Oversight 911, the Ombudsman makes 53 recommendations to overhaul the Ministry’s oversight of land and air ambulances. All of his recommendations have been accepted.

“Emergency ambulance service can mean the difference between life and death – and we see this now more than ever, as our medical services struggle with the COVID-19 pandemic,” Mr. Dubé said.

“It is the Ministry that has primary responsibility for ensuring that the emergency health care patients receive is consistent with the law and service standards. It has neglected patient safety by failing to adequately monitor EMS providers, dispatch centres, and Ornge,” he writes in the report.

The Ombudsman found the Ministry’s processes “unreasonable and wrong” under the Ombudsman Act, and identified several serious concerns, for example:

  • Serious issues were often not investigated because the Ministry viewed matters such as paramedics’ conduct, medication errors or customer service problems as outside of its purview.

  • Few protocols existed for how reviews and investigations should be conducted, investigators lacked training and expertise, and the subjects of investigations had little input into the Ministry’s findings.

  • Understaffing and high turnover contributed to long delays in investigation reports and led to a backlog of thousands of incident reports.

  • Patients lacked information on how to complain about ambulance services, and those who did were at times not interviewed or told of the outcome of investigations.

  • There was no centralized way to store investigation reports or track systemic trends, no follow-up to ensure problems didn’t recur, and best practices were not shared across the system.

The investigation, conducted by the Special Ombudsman Response Team (SORT), was prompted by complaints from patients, their families and a whistleblower, and looked into 72 complaints in total. The Ombudsman’s investigators reviewed tens of thousands of pages of documentation, including many of the Ministry’s investigation files and incident reports. They also conducted 60 interviews with Ministry officials, industry stakeholders, complainants and whistleblowers from across the system.

The Ombudsman’s recommendations include overhauling the complaint handling process and enhancing central oversight; improving how staff conduct investigations; making reports and reviews more consistent; and implementing databases to track and resolve complaints and systemic trends.
The Ombudsman’s investigation was completed in early 2020, but the pandemic understandably delayed the Ministry’s response to his findings. The Ombudsman noted that his office received excellent co-operation from the Ministry, which will report to him on its progress in implementing the recommendations.

“With so many people being transported by ambulance due to the pandemic, the changes we are recommending are timely and valuable,” Mr. Dubé said. “Ontarians deserve better oversight of ambulance services, and I am pleased that the Ministry has recognized this.”

The Ministry of Health has already acted on several of the recommendations – for instance, it has drafted new investigation and training-related policies and begun recruiting additional staff.

The Ombudsman is an independent, impartial officer of the Ontario Legislature who resolves and investigates some 20,000 public complaints per year about provincial government bodies, as well as French language services, child protection services, municipalities, universities and school boards. He does not overturn decisions of elected officials or set public policy, but makes recommendations to ensure administrative fairness, transparency and accountability. The Ombudsman’s recommendations have been overwhelmingly accepted by government, resulting in numerous reforms, including help for people with developmental disabilities who are in crisis, improved drug funding and newborn screening, and enhanced tracking of inmates in solitary confinement.

Ombudsman Dubé will be available between 1-4 p.m. for interviews Thursday, May 20. Please contact Director of Communications Linda Williamson to arrange an interview.

For more information, contact:
Linda Williamson, Director of Communications