Coroner Inquest Ends With Recommendations Anzovino Family Feels Satisfied With

 By Doug Draper

 The coroner’s inquest into the death two Christmas season ago of Fort Erie, Ontario teen Reilly Anzovino is over and it spawned 27 recommendations in all for improving responses to traffic collisions that result in life-threatening injuries.

With Tim Anzovino, Reilly's father to the right, family member Patricia Anzovino behind her and lawyer Maureen Currie to the left, Reilly's mother, Denise Kennedy, reads statement at conclusion of inquest. Photo by Doug Draper

 The recommendations came from a five-person jury in a Welland courtroom after those jurors listened to three weeks of evidence, involving the testimony of about three dozen witnesses, and at the end of the day, the Anzovino family said it was satisfied with the results.

Denise Kennedy, Reilly’s mother, said after the jury completed its deliberations his December 21 that the family hopes the recommendations, if followed through by various levels of government, will prevent other families from suffering the tragedy her family did.

 Those recommendations include reviewing the need for a centre to deal with trauma patients in Niagara and the need for paramedics to adhere, as much as possible, to a 10-minute standard when it comes to loading patients on an ambulance and rushing off to a hospital. In this inquest, there were concerns raised about the roughly 17 minutes of time it took for paramedics to leave the scene of the accident after  Reilly was placed in the ambulance.

 For south Niagara residents who may have been hoping the inquest would lead to recommendations for reopening emergency rooms in Fort Erie and Port Colborne, that did not happen and there are reasons for that which Niagara At Large will discuss in commentary in the days ahead.

 In the meantime, we are posting a transcript of a statement Denise Kennedy made on behalf of the Kennedy/Anzovino family, followed the recommendations tabled by the jury.

 When we wrote to the Chief Coroner almost two years ago to request and support a discretionary inquest into Reilly’s death, our sole purpose was to seek answers for ourselves and our community that we could not get on our own; and to help prevent deaths in similar circumstances.

 We will always have questions about the events that took place that horrible night. We will never have complete peace in our hearts. But one thing we will always have;  is peace knowing that we have done everything possible to give Reilly a voice and everything possible to make positive change to ensure that what happened to Reilly, and the pain our family and friends went through, hopefully does not happen again.

 At every level of care Reilly and our family were let down in some way. We have peace knowing that through this Inquest process those errors were exposed and our hope for the future is that other families will be spared some of this pain by ways of prevention, through education, and unfortunately lessons learned.

 We have faith knowing now that this Inquest process has done that in many ways.

 We are extremely thankful to the Honorable Coroner; Dr. Jack Stanborough for his compassion, his integrity, his honesty and his wisdom and most of all his powerful words; “We speak for the dead to protect the living.” Those words will be etched in our hearts forever. Those words give us peace in our hearts knowing that someone was speaking for Reilly when she could not do so herself.

 We are truly thankful to the Coroner’s Constable Mr. Bill Anand for his kindness and tentative nature and supplying us with anything we needed. We are deeply thankful to the Jury and the other council members for their time and great effort throughout this process. Families and friends were neglected temporarily and we do not get that time back, but change lasts forever and I believe we all accomplished that.

As a family we could never say in words how we feel about the support of members of our community, the local press and Reilly’s friends for their commitment and faithfulness to our family and most of all to Reilly.

Finally we want to specially thank Maureen Currie (who took on the role as the Anzovino/Kenney’s family solicitor at the inquest), her husband and family who have also suffered a great loss with their son “Kevin” one month prior to Reilly’s death.

Maureen was requested to represent us in this Inquest; partially through this process. We could not have found someone more capable, more dedicated and more honest to represent us and Reilly. All while still suffering from their own pain and loss.

 We believe that fate did have a hand in assisting us to find Maureen and through this process she has helped to change our lives and many lives forever. For that we are truly grateful.

 Thank you,

 Now here are the recommendations, with headings to each of the agencies the jury hopes will adopt them. Be advised that Niagara At Large has placed in brackets the full name of agencies identified in the jurors’ recommendations with acronyms.

 Niagara Health System

1. We encourage the NHS (Niagara Health System) to conduct a study in conjunction with the LHIN (Hamilton Niagara Haldimand Brant Local Health Integration Network) and in consultation with HHCS (Hamilton Health Sciences Centre) as to the feasibility of concentrating resources and trauma patients at one of the hospital sites of the NHS.

2. We encourage the implementation of a trauma alert code in the NHS (i.e. early notification system for mobilizing the appropriate medical personnel).

3. We encourage the NHS to continue developing a procedure for communicating information that is received from paramedics via radio patch that will ensure that the information is communicated quickly to nursing staff, including the Charge Nurse, in the emergency department.

Niagara Emergency Medical Services

4. We recommend that the NEMS (Niagara Emergency Medical Services) continue to collect “Load and Go” CTAS 1 and 2 patient care data for the purpose of ensuring completeness, accuracy, compliance with and educating paramedics about the importance of adhering to BLS and ALS standards. NEMS should continue its practice of reviewing any unwarranted or undocumented breach of these standards and make a consideration of appropriate action for any such breach that occurs without a reasonable and documented explanation. All reviews of CTAS 1 and 2 trauma patient care, where the care unreasonably fails to meet the BLS or ALS standards, should continue to be forwarded to the

Base Hospital Physicians and the MOHLTC

5. We recommend that a feasibility study be done about the possibility of installing video and/or sound recording equipment in ambulances for the purpose of quality of care review.

Ministry of Health and Long-Term Care

6. We recommend that the MOHLTC (Ontario Ministry of Health and Long Term Care), with input from MAC, should change the Field Trauma Triage Guideline to expand the parametres within which paramedics may choose to take a patient to a lead trauma hospital in Canada without having to seek approval from a Base Hospital physician to 30 minutes driving time from the scene (as opposed to time starting at patient assessment).

7. We recommend that the MOHLTC consider whether all of the Base Hospitals and Ontario EMS operators should be included within a patient’s “circle of care” such that they are entitled to share data on patient outcomes after patients have been delivered by paramedics to hospitals.

8. We recommend that the MOHLTC be encouraged to continue its efforts to develop a provincewide method for automated Computer Aided Dispatch (CAD) data transfer between provincially operated communications centres and regional or municipal emergency medical services, such that appropriate fields in patient care and/or ambulance reports will be automatically populated. MOHLTC should consider the best available data features from the NEMS communications model and incorporate them into the province-wide method.

9. We recommend that as an interim measure if the technology is already available pending the development of a provincewide solution for data transfer between the communications centre and electronic patient care reports of municipal or regional emergency medical services (as referred to in recommendation 8), we encourage the MOHLTC to allow NEWS to transfer Computer Aided Disptach (CAD) data automatically and electronically from the Communications Centre for Niagara such that the appropriate fields in the electronic Patient Care Report are automatically populated.

Ontario Emergency Medical Services

10. We encourage Ontario EMS operators to review their training and practices concerning means of capturing and documenting the nature and sequence of procedures and interventions used during patient care. We encourage use of any means currently available that may improve documentation, such as the use of event buttons on cardiac monitors. While patient care always takes precedence, such documentation may be valuable to quality of care reviews and researchers as data for evidence-based medicine. When current equipment is due to be replaced, consideration should be given to acquiring equipment that will assist in facilitating data capture in an effective and efficient manner.

11. We recommend that all Ontario EMS operators be encouraged to review whether there is a need for technology or other means of facilitating ease of communication between the driver of an ambulance and the paramedic who is providing patient care.

12 We recommend that all Ontario EMS operators ensure that all paramedics understand that “Load and Go” is an expected standard to be met unless exceptional circumstances exist. In any CTAS 1 and 2 cases where this standard is not met appropriate documentation and incident report should be filled out and provided to their base hospital for its consideration and ensuing review.

13. We recommend that it should be reinforced to all paramedics in Ontario that the BLS and ALS standards are not guidelines or motivators and must be followed as written; otherwise, provide documentation in the chart explaining why the standards could not be achieved.

14. We recommend that all Ontario EMS secure ambulance doors when on scene to minimize preventable delay.

Ontario Association of Fire Chiefs

15. We recommend that all firefighters who assist paramedics in providing patient care should complete a Medical Assistance Report (MAR) documenting their involvement in the care of the patient and should be forwarded to the local EMS operator to form part of the Patient Care Report.

Federal Minister of Justice

16. We recommend a review of section 254(2) of the Criminal Code to replace the requirement that peace officers have “reasonable grounds to suspect alcohol” with “any grounds to suspect alcohol” for roadside breath demands. This would assist peace officers in promoting road safety.

Ministry of Community Safety and Correctional Services

17. We recommend the MCSCS review the training delivered to all new police recruits in Ontario concerning drinking and driving. Training should emphasize the nature of the thresholds set out in the Criminal Code of Canada as to what circumstances or collection of circumstances may constitute “reasonable grounds to suspect” that someone operating a motor vehicle may have alcohol in their body such that a demand may be made by the officer for a roadside screening test. One of the goals of the training should be to encourage greater consistency in what constitutes “reasonable grounds to suspect.”

18. We recommend that if the review in recommendation 17 leads to an update in training new police recruits concerning the application of the Criminal Code thresholds for demanding a roadside screening test for alcohol, the MCSCS should notify all provincial, regional and municipal police services that they may consider updating their training in this regard.

19. We recommend that if police officers make one or more observations that may constitute reasonable grounds to suspect that someone operating a motor vehicle has alcohol in his/her body, but the officer exercises their discretion not to demand a roadside screening test, that the officer should document the reasons for that decision. For example, a test may not be conducted because the driver is unable to perform it due to their medical condition. The MCSCS and individual police services should develop a practice for review of such documentation. If it is not practical to do so in all cases, then the review of the documentation should occur in a timely manner in cases identified as being serious.

Ministry of Transportation

20. We encourage the MTO (Ontario Ministry of Transportaion) and the Region of Niagara to explore whether it is feasible to facilitate the sharing of information regarding road conditions on a real-time basis, so that deteriorating road conditions may be responded to promptly and thereby make driving conditions safer for motorists in the region, regardless of whether the province or region have responsibility for maintaing a particular roadway.

Hamilton Niagara Haldimand Brant Local Health Integration Network and MOHLTC

21. We recommend that this case be used as an educational example for base hospitals and all paramedic training in Ontario.

22. We recommend that the International Trauma Life Support (ITLS) continuing medical education program be mandatory for all paramedics across the province of Ontario.

Ontario Ministry of Training, Colleges and Universities

23. We recommend that the Ontario Ministry of Training, Colleges and Universities examine the curriculum of paramedic education in Ontario to ensure adequate education in trauma care.

Ministry of Health and Long-Term Care & Niagara Health System & Niagara Emergency Medical Services & ORNGE

24. We recommend all parties enter into discussions to determine the need, if any, for critical-care paramedic services for hospital to hospital transfers of appropriate patients in the Niagara region. The discussions should consider whether or not there is a need for ORNGE critical care land ambulance services to be available in Niagara region for appropriate patients, particularly when weather, darkness or other conditions may mean that ORNGE air ambulance is unavailable.

Ministry of Health and Long-Term Care & Base Hospitals

25. In addition to the “Load and Go” content contained in the ITLS course, we encourage the MOHLTC to review training and/or standards provided to paramedics concerning the “Load and Go Patients Standard” set out in the Basic Life Support Patient Care Standards. The review should ensure that the training and standards rely on evidence-based medicine. Any required medical interventions should be attempted enroute to hospital and should not delay the departure from the scene.

Ministry of Health and Long-Term Care & Regional Municipalities & Base Hospitals & Ontario Emergency Medical Services

26. We recommend that the Base Hospitals and/or MAC should be involved in quality review of care provided under both the BLS and ALS standards.

Ministry of Health and Long-Term Care & The Ontario Hospital Association & Ontario Emergency Medical Services

27. We recommend that efforts continue to ensure consistent criteria for CTAS scores used by hospitals and EMS throughout Ontario.

(We invite you to share your views below.)

NAL FINAL coroners inquest, December

Coroner Inquest Ends With Recommendations Anzovino Family Feels Satisfied With

By Doug Draper

The coroner’s inquest into the death two Christmas season ago of Fort Erie, Ontario teen Reilly Anzovino is over and it spawned 27 recommendations in all for improving responses to traffic collisions that result in life-threatening injuries.

The recommendations came from a five-person jury in a Welland courtroom after those jurors listened to three weeks of evidence, involving the testimony of about three dozen witnesses, and at the end of the day, the Anzovino family said it was satisfied with the results.

Denise Kennedy, Reilly’s mother, said after the jury completed its deliberations his December 21 that the family hopes the recommendations, if followed through by various levels of government, will prevent other families from suffering the tragedy her family did.

Those recommendations include reviewing the need for a centre to deal with trauma patients in Niagara and the need for paramedics to adhere, as much as possible, to a 10-minute standard when it comes to loading patients on an ambulance and rushing off to a hospital. In this inquest, there were concerns raised about the roughly 17 minutes of time it took for paramedics to leave the scene of the accident after  Reilly was placed in the ambulance.

For south Niagara residents who may have been hoping the inquest would lead to recommendations for reopening emergency rooms in Fort Erie and Port Colborne, that did not happen and there are reasons for that which Niagara At Large will discuss in commentary in the days ahead.

In the meantime, we are posting a transcript of a statement Denise Kennedy made on behalf of the Kennedy/Anzovino family, followed the recommendations tabled by the jury.

When we wrote to the Chief Coroner almost two years ago to request and support a discretionary inquest into Reilly’s death, our sole purpose was to seek answers for ourselves and our community that we could not get on our own; and to help prevent deaths in similar circumstances.

We will always have questions about the events that took place that horrible night. We will never have complete peace in our hearts. But one thing we will always have;  is peace knowing that we have done everything possible to give Reilly a voice and everything possible to make positive change to ensure that what happened to Reilly, and the pain our family and friends went through, hopefully does not happen again.

At every level of care Reilly and our family were let down in some way. We have peace knowing that through this Inquest process those errors were exposed and our hope for the future is that other families will be spared some of this pain by ways of prevention, through education, and unfortunately lessons learned.

We have faith knowing now that this Inquest process has done that in many ways.

We are extremely thankful to the Honorable Coroner; Dr. Jack Stanborough for his compassion, his integrity, his honesty and his wisdom and most of all his powerful words; “We speak for the dead to protect the living.” Those words will be etched in our hearts forever. Those words give us peace in our hearts knowing that someone was speaking for Reilly when she could not do so herself.

We are truly thankful to the Coroner’s Constable Mr. Bill Anand for his kindness and tentative nature and supplying us with anything we needed. We are deeply thankful to the Jury and the other council members for their time and great effort throughout this process. Families and friends were neglected temporarily and we do not get that time back, but change lasts forever and I believe we all accomplished that.

As a family we could never say in words how we feel about the support of members of our community, the local press and Reilly’s friends for their commitment and faithfulness to our family and most of all to Reilly.

Finally we want to specially thank Maureen Currie (who took on the role as the Anzovino/Kenney’s family solicitor at the inquest), her husband and family who have also suffered a great loss with their son “Kevin” one month prior to Reilly’s death.

 

Maureen was requested to represent us in this Inquest; partially through this process. We could not have found someone more capable, more dedicated and more honest to represent us and Reilly. All while still suffering from their own pain and loss.

We believe that fate did have a hand in assisting us to find Maureen and through this process she has helped to change our lives and many lives forever. For that we are truly grateful.

 

Thank you,

Now here are the recommendations, with headings to each of the agencies the jury hopes will adopt them. Be advised that Niagara At Large has placed in brackets the full name of agencies identified in the jurors’ recommendations with acronyms.

Niagara Health System

1. We encourage the NHS (Niagara Health System) to conduct a study in conjunction with the LHIN (Hamilton Niagara Haldimand Brant Local Health Integration Network) and in consultation with HHCS (Hamilton Health Sciences Centre) as to the feasibility of concentrating resources and trauma patients at one of the hospital sites of the NHS.

2. We encourage the implementation of a trauma alert code in the NHS (i.e. early notification system for mobilizing the appropriate medical personnel).

3. We encourage the NHS to continue developing a procedure for communicating information that is received from paramedics via radio patch that will ensure that the information is communicated quickly to nursing staff, including the Charge Nurse, in the emergency department.

Niagara Emergency Medical Services

4. We recommend that the NEMS (Niagara Emergency Medical Services) continue to collect “Load and Go” CTAS 1 and 2 patient care data for the purpose of ensuring completeness, accuracy, compliance with and educating paramedics about the importance of adhering to BLS and ALS standards. NEMS should continue its practice of reviewing any unwarranted or undocumented breach of these standards and make a consideration of appropriate action for any such breach that occurs without a reasonable and documented explanation. All reviews of CTAS 1 and 2 trauma patient care, where the care unreasonably fails to meet the BLS or ALS standards, should continue to be forwarded to the

Base Hospital Physicians and the MOHLTC

5. We recommend that a feasibility study be done about the possibility of installing video and/or sound recording equipment in ambulances for the purpose of quality of care review.

Ministry of Health and Long-Term Care

6. We recommend that the MOHLTC (Ontario Ministry of Health and Long Term Care), with input from MAC, should change the Field Trauma Triage Guideline to expand the parametres within which paramedics may choose to take a patient to a lead trauma hospital in Canada without having to seek approval from a Base Hospital physician to 30 minutes driving time from the scene (as opposed to time starting at patient assessment).

7. We recommend that the MOHLTC consider whether all of the Base Hospitals and Ontario EMS operators should be included within a patient’s “circle of care” such that they are entitled to share data on patient outcomes after patients have been delivered by paramedics to hospitals.

8. We recommend that the MOHLTC be encouraged to continue its efforts to develop a provincewide method for automated Computer Aided Dispatch (CAD) data transfer between provincially operated communications centres and regional or municipal emergency medical services, such that appropriate fields in patient care and/or ambulance reports will be automatically populated. MOHLTC should consider the best available data features from the NEMS communications model and incorporate them into the province-wide method.

9. We recommend that as an interim measure if the technology is already available pending the development of a provincewide solution for data transfer between the communications centre and electronic patient care reports of municipal or regional emergency medical services (as referred to in recommendation 8), we encourage the MOHLTC to allow NEWS to transfer Computer Aided Disptach (CAD) data automatically and electronically from the Communications Centre for Niagara such that the appropriate fields in the electronic Patient Care Report are automatically populated.

Ontario Emergency Medical Services

10. We encourage Ontario EMS operators to review their training and practices concerning means of capturing and documenting the nature and sequence of procedures and interventions used during patient care. We encourage use of any means currently available that may improve documentation, such as the use of event buttons on cardiac monitors. While patient care always takes precedence, such documentation may be valuable to quality of care reviews and researchers as data for evidence-based medicine. When current equipment is due to be replaced, consideration should be given to acquiring equipment that will assist in facilitating data capture in an effective and efficient manner.

11. We recommend that all Ontario EMS operators be encouraged to review whether there is a need for technology or other means of facilitating ease of communication between the driver of an ambulance and the paramedic who is providing patient care.

12 We recommend that all Ontario EMS operators ensure that all paramedics understand that “Load and Go” is an expected standard to be met unless exceptional circumstances exist. In any CTAS 1 and 2 cases where this standard is not met appropriate documentation and incident report should be filled out and provided to their base hospital for its consideration and ensuing review.

13. We recommend that it should be reinforced to all paramedics in Ontario that the BLS and ALS standards are not guidelines or motivators and must be followed as written; otherwise, provide documentation in the chart explaining why the standards could not be achieved.

14. We recommend that all Ontario EMS secure ambulance doors when on scene to minimize preventable delay.

Ontario Association of Fire Chiefs

15. We recommend that all firefighters who assist paramedics in providing patient care should complete a Medical Assistance Report (MAR) documenting their involvement in the care of the patient and should be forwarded to the local EMS operator to form part of the Patient Care Report.

Federal Minister of Justice

16. We recommend a review of section 254(2) of the Criminal Code to replace the requirement that peace officers have “reasonable grounds to suspect alcohol” with “any grounds to suspect alcohol” for roadside breath demands. This would assist peace officers in promoting road safety.

Ministry of Community Safety and Correctional Services

17. We recommend the MCSCS review the training delivered to all new police recruits in Ontario concerning drinking and driving. Training should emphasize the nature of the thresholds set out in the Criminal Code of Canada as to what circumstances or collection of circumstances may constitute “reasonable grounds to suspect” that someone operating a motor vehicle may have alcohol in their body such that a demand may be made by the officer for a roadside screening test. One of the goals of the training should be to encourage greater consistency in what constitutes “reasonable grounds to suspect.”

18. We recommend that if the review in recommendation 17 leads to an update in training new police recruits concerning the application of the Criminal Code thresholds for demanding a roadside screening test for alcohol, the MCSCS should notify all provincial, regional and municipal police services that they may consider updating their training in this regard.

19. We recommend that if police officers make one or more observations that may constitute reasonable grounds to suspect that someone operating a motor vehicle has alcohol in his/her body, but the officer exercises their discretion not to demand a roadside screening test, that the officer should document the reasons for that decision. For example, a test may not be conducted because the driver is unable to perform it due to their medical condition. The MCSCS and individual police services should develop a practice for review of such documentation. If it is not practical to do so in all cases, then the review of the documentation should occur in a timely manner in cases identified as being serious.

Ministry of Transportation

20. We encourage the MTO (Ontario Ministry of Transportaion) and the Region of Niagara to explore whether it is feasible to facilitate the sharing of information regarding road conditions on a real-time basis, so that deteriorating road conditions may be responded to promptly and thereby make driving conditions safer for motorists in the region, regardless of whether the province or region have responsibility for maintaing a particular roadway.

Hamilton Niagara Haldimand Brant Local Health Integration Network and MOHLTC

21. We recommend that this case be used as an educational example for base hospitals and all paramedic training in Ontario.

22. We recommend that the International Trauma Life Support (ITLS) continuing medical education program be mandatory for all paramedics across the province of Ontario.

Ontario Ministry of Training, Colleges and Universities

23. We recommend that the Ontario Ministry of Training, Colleges and Universities examine the curriculum of paramedic education in Ontario to ensure adequate education in trauma care.

Ministry of Health and Long-Term Care & Niagara Health System & Niagara Emergency Medical Services & ORNGE

24. We recommend all parties enter into discussions to determine the need, if any, for critical-care paramedic services for hospital to hospital transfers of appropriate patients in the Niagara region. The discussions should consider whether or not there is a need for ORNGE critical care land ambulance services to be available in Niagara region for appropriate patients, particularly when weather, darkness or other conditions may mean that ORNGE air ambulance is unavailable.

Ministry of Health and Long-Term Care & Base Hospitals

25. In addition to the “Load and Go” content contained in the ITLS course, we encourage the MOHLTC to review training and/or standards provided to paramedics concerning the “Load and Go Patients Standard” set out in the Basic Life Support Patient Care Standards. The review should ensure that the training and standards rely on evidence-based medicine. Any required medical interventions should be attempted enroute to hospital and should not delay the departure from the scene.

Ministry of Health and Long-Term Care & Regional Municipalities & Base Hospitals & Ontario Emergency Medical Services

26. We recommend that the Base Hospitals and/or MAC should be involved in quality review of care provided under both the BLS and ALS standards.

Ministry of Health and Long-Term Care & The Ontario Hospital Association & Ontario Emergency Medical Services

27. We recommend that efforts continue to ensure consistent criteria for CTAS scores used by hospitals and EMS throughout Ontario.

(We invite you to share your views below.)

NAL FINAL coroners inquest, December

Coroner Inquest Ends With Recommendations Anzovino Family Feels Satisfied With

By Doug Draper

The coroner’s inquest into the death two Christmas season ago of Fort Erie, Ontario teen Reilly Anzovino is over and it spawned 27 recommendations in all for improving responses to traffic collisions that result in life-threatening injuries.

The recommendations came from a five-person jury in a Welland courtroom after those jurors listened to three weeks of evidence, involving the testimony of about three dozen witnesses, and at the end of the day, the Anzovino family said it was satisfied with the results.

Denise Kennedy, Reilly’s mother, said after the jury completed its deliberations his December 21 that the family hopes the recommendations, if followed through by various levels of government, will prevent other families from suffering the tragedy her family did.

Those recommendations include reviewing the need for a centre to deal with trauma patients in Niagara and the need for paramedics to adhere, as much as possible, to a 10-minute standard when it comes to loading patients on an ambulance and rushing off to a hospital. In this inquest, there were concerns raised about the roughly 17 minutes of time it took for paramedics to leave the scene of the accident after  Reilly was placed in the ambulance.

For south Niagara residents who may have been hoping the inquest would lead to recommendations for reopening emergency rooms in Fort Erie and Port Colborne, that did not happen and there are reasons for that which Niagara At Large will discuss in commentary in the days ahead.

In the meantime, we are posting a transcript of a statement Denise Kennedy made on behalf of the Kennedy/Anzovino family, followed the recommendations tabled by the jury.

When we wrote to the Chief Coroner almost two years ago to request and support a discretionary inquest into Reilly’s death, our sole purpose was to seek answers for ourselves and our community that we could not get on our own; and to help prevent deaths in similar circumstances.

We will always have questions about the events that took place that horrible night. We will never have complete peace in our hearts. But one thing we will always have;  is peace knowing that we have done everything possible to give Reilly a voice and everything possible to make positive change to ensure that what happened to Reilly, and the pain our family and friends went through, hopefully does not happen again.

At every level of care Reilly and our family were let down in some way. We have peace knowing that through this Inquest process those errors were exposed and our hope for the future is that other families will be spared some of this pain by ways of prevention, through education, and unfortunately lessons learned.

We have faith knowing now that this Inquest process has done that in many ways.

We are extremely thankful to the Honorable Coroner; Dr. Jack Stanborough for his compassion, his integrity, his honesty and his wisdom and most of all his powerful words; “We speak for the dead to protect the living.” Those words will be etched in our hearts forever. Those words give us peace in our hearts knowing that someone was speaking for Reilly when she could not do so herself.

We are truly thankful to the Coroner’s Constable Mr. Bill Anand for his kindness and tentative nature and supplying us with anything we needed. We are deeply thankful to the Jury and the other council members for their time and great effort throughout this process. Families and friends were neglected temporarily and we do not get that time back, but change lasts forever and I believe we all accomplished that.

As a family we could never say in words how we feel about the support of members of our community, the local press and Reilly’s friends for their commitment and faithfulness to our family and most of all to Reilly.

Finally we want to specially thank Maureen Currie (who took on the role as the Anzovino/Kenney’s family solicitor at the inquest), her husband and family who have also suffered a great loss with their son “Kevin” one month prior to Reilly’s death.

 

Maureen was requested to represent us in this Inquest; partially through this process. We could not have found someone more capable, more dedicated and more honest to represent us and Reilly. All while still suffering from their own pain and loss.

We believe that fate did have a hand in assisting us to find Maureen and through this process she has helped to change our lives and many lives forever. For that we are truly grateful.

 

Thank you,

Now here are the recommendations, with headings to each of the agencies the jury hopes will adopt them. Be advised that Niagara At Large has placed in brackets the full name of agencies identified in the jurors’ recommendations with acronyms.

Niagara Health System

1. We encourage the NHS (Niagara Health System) to conduct a study in conjunction with the LHIN (Hamilton Niagara Haldimand Brant Local Health Integration Network) and in consultation with HHCS (Hamilton Health Sciences Centre) as to the feasibility of concentrating resources and trauma patients at one of the hospital sites of the NHS.

2. We encourage the implementation of a trauma alert code in the NHS (i.e. early notification system for mobilizing the appropriate medical personnel).

3. We encourage the NHS to continue developing a procedure for communicating information that is received from paramedics via radio patch that will ensure that the information is communicated quickly to nursing staff, including the Charge Nurse, in the emergency department.

Niagara Emergency Medical Services

4. We recommend that the NEMS (Niagara Emergency Medical Services) continue to collect “Load and Go” CTAS 1 and 2 patient care data for the purpose of ensuring completeness, accuracy, compliance with and educating paramedics about the importance of adhering to BLS and ALS standards. NEMS should continue its practice of reviewing any unwarranted or undocumented breach of these standards and make a consideration of appropriate action for any such breach that occurs without a reasonable and documented explanation. All reviews of CTAS 1 and 2 trauma patient care, where the care unreasonably fails to meet the BLS or ALS standards, should continue to be forwarded to the

Base Hospital Physicians and the MOHLTC

5. We recommend that a feasibility study be done about the possibility of installing video and/or sound recording equipment in ambulances for the purpose of quality of care review.

Ministry of Health and Long-Term Care

6. We recommend that the MOHLTC (Ontario Ministry of Health and Long Term Care), with input from MAC, should change the Field Trauma Triage Guideline to expand the parametres within which paramedics may choose to take a patient to a lead trauma hospital in Canada without having to seek approval from a Base Hospital physician to 30 minutes driving time from the scene (as opposed to time starting at patient assessment).

7. We recommend that the MOHLTC consider whether all of the Base Hospitals and Ontario EMS operators should be included within a patient’s “circle of care” such that they are entitled to share data on patient outcomes after patients have been delivered by paramedics to hospitals.

8. We recommend that the MOHLTC be encouraged to continue its efforts to develop a provincewide method for automated Computer Aided Dispatch (CAD) data transfer between provincially operated communications centres and regional or municipal emergency medical services, such that appropriate fields in patient care and/or ambulance reports will be automatically populated. MOHLTC should consider the best available data features from the NEMS communications model and incorporate them into the province-wide method.

9. We recommend that as an interim measure if the technology is already available pending the development of a provincewide solution for data transfer between the communications centre and electronic patient care reports of municipal or regional emergency medical services (as referred to in recommendation 8), we encourage the MOHLTC to allow NEWS to transfer Computer Aided Disptach (CAD) data automatically and electronically from the Communications Centre for Niagara such that the appropriate fields in the electronic Patient Care Report are automatically populated.

Ontario Emergency Medical Services

10. We encourage Ontario EMS operators to review their training and practices concerning means of capturing and documenting the nature and sequence of procedures and interventions used during patient care. We encourage use of any means currently available that may improve documentation, such as the use of event buttons on cardiac monitors. While patient care always takes precedence, such documentation may be valuable to quality of care reviews and researchers as data for evidence-based medicine. When current equipment is due to be replaced, consideration should be given to acquiring equipment that will assist in facilitating data capture in an effective and efficient manner.

11. We recommend that all Ontario EMS operators be encouraged to review whether there is a need for technology or other means of facilitating ease of communication between the driver of an ambulance and the paramedic who is providing patient care.

12 We recommend that all Ontario EMS operators ensure that all paramedics understand that “Load and Go” is an expected standard to be met unless exceptional circumstances exist. In any CTAS 1 and 2 cases where this standard is not met appropriate documentation and incident report should be filled out and provided to their base hospital for its consideration and ensuing review.

13. We recommend that it should be reinforced to all paramedics in Ontario that the BLS and ALS standards are not guidelines or motivators and must be followed as written; otherwise, provide documentation in the chart explaining why the standards could not be achieved.

14. We recommend that all Ontario EMS secure ambulance doors when on scene to minimize preventable delay.

Ontario Association of Fire Chiefs

15. We recommend that all firefighters who assist paramedics in providing patient care should complete a Medical Assistance Report (MAR) documenting their involvement in the care of the patient and should be forwarded to the local EMS operator to form part of the Patient Care Report.

Federal Minister of Justice

16. We recommend a review of section 254(2) of the Criminal Code to replace the requirement that peace officers have “reasonable grounds to suspect alcohol” with “any grounds to suspect alcohol” for roadside breath demands. This would assist peace officers in promoting road safety.

Ministry of Community Safety and Correctional Services

17. We recommend the MCSCS review the training delivered to all new police recruits in Ontario concerning drinking and driving. Training should emphasize the nature of the thresholds set out in the Criminal Code of Canada as to what circumstances or collection of circumstances may constitute “reasonable grounds to suspect” that someone operating a motor vehicle may have alcohol in their body such that a demand may be made by the officer for a roadside screening test. One of the goals of the training should be to encourage greater consistency in what constitutes “reasonable grounds to suspect.”

18. We recommend that if the review in recommendation 17 leads to an update in training new police recruits concerning the application of the Criminal Code thresholds for demanding a roadside screening test for alcohol, the MCSCS should notify all provincial, regional and municipal police services that they may consider updating their training in this regard.

19. We recommend that if police officers make one or more observations that may constitute reasonable grounds to suspect that someone operating a motor vehicle has alcohol in his/her body, but the officer exercises their discretion not to demand a roadside screening test, that the officer should document the reasons for that decision. For example, a test may not be conducted because the driver is unable to perform it due to their medical condition. The MCSCS and individual police services should develop a practice for review of such documentation. If it is not practical to do so in all cases, then the review of the documentation should occur in a timely manner in cases identified as being serious.

Ministry of Transportation

20. We encourage the MTO (Ontario Ministry of Transportaion) and the Region of Niagara to explore whether it is feasible to facilitate the sharing of information regarding road conditions on a real-time basis, so that deteriorating road conditions may be responded to promptly and thereby make driving conditions safer for motorists in the region, regardless of whether the province or region have responsibility for maintaing a particular roadway.

Hamilton Niagara Haldimand Brant Local Health Integration Network and MOHLTC

21. We recommend that this case be used as an educational example for base hospitals and all paramedic training in Ontario.

22. We recommend that the International Trauma Life Support (ITLS) continuing medical education program be mandatory for all paramedics across the province of Ontario.

Ontario Ministry of Training, Colleges and Universities

23. We recommend that the Ontario Ministry of Training, Colleges and Universities examine the curriculum of paramedic education in Ontario to ensure adequate education in trauma care.

Ministry of Health and Long-Term Care & Niagara Health System & Niagara Emergency Medical Services & ORNGE

24. We recommend all parties enter into discussions to determine the need, if any, for critical-care paramedic services for hospital to hospital transfers of appropriate patients in the Niagara region. The discussions should consider whether or not there is a need for ORNGE critical care land ambulance services to be available in Niagara region for appropriate patients, particularly when weather, darkness or other conditions may mean that ORNGE air ambulance is unavailable.

Ministry of Health and Long-Term Care & Base Hospitals

25. In addition to the “Load and Go” content contained in the ITLS course, we encourage the MOHLTC to review training and/or standards provided to paramedics concerning the “Load and Go Patients Standard” set out in the Basic Life Support Patient Care Standards. The review should ensure that the training and standards rely on evidence-based medicine. Any required medical interventions should be attempted enroute to hospital and should not delay the departure from the scene.

Ministry of Health and Long-Term Care & Regional Municipalities & Base Hospitals & Ontario Emergency Medical Services

26. We recommend that the Base Hospitals and/or MAC should be involved in quality review of care provided under both the BLS and ALS standards.

Ministry of Health and Long-Term Care & The Ontario Hospital Association & Ontario Emergency Medical Services

27. We recommend that efforts continue to ensure consistent criteria for CTAS scores used by hospitals and EMS throughout Ontario.

(We invite you to share your views below.)

Coroner Inquest Ends With Recommendations Anzovino Family Feels Satisfied With

By Doug Draper

The coroner’s inquest into the death two Christmas season ago of Fort Erie, Ontario teen Reilly Anzovino is over and it spawned 27 recommendations in all for improving responses to traffic collisions that result in life-threatening injuries.

The recommendations came from a five-person jury in a Welland courtroom after those jurors listened to three weeks of evidence, involving the testimony of about three dozen witnesses, and at the end of the day, the Anzovino family said it was satisfied with the results.

Denise Kennedy, Reilly’s mother, said after the jury completed its deliberations his December 21 that the family hopes the recommendations, if followed through by various levels of government, will prevent other families from suffering the tragedy her family did.

Those recommendations include reviewing the need for a centre to deal with trauma patients in Niagara and the need for paramedics to adhere, as much as possible, to a 10-minute standard when it comes to loading patients on an ambulance and rushing off to a hospital. In this inquest, there were concerns raised about the roughly 17 minutes of time it took for paramedics to leave the scene of the accident after  Reilly was placed in the ambulance.

For south Niagara residents who may have been hoping the inquest would lead to recommendations for reopening emergency rooms in Fort Erie and Port Colborne, that did not happen and there are reasons for that which Niagara At Large will discuss in commentary in the days ahead.

In the meantime, we are posting a transcript of a statement Denise Kennedy made on behalf of the Kennedy/Anzovino family, followed the recommendations tabled by the jury.

When we wrote to the Chief Coroner almost two years ago to request and support a discretionary inquest into Reilly’s death, our sole purpose was to seek answers for ourselves and our community that we could not get on our own; and to help prevent deaths in similar circumstances.

We will always have questions about the events that took place that horrible night. We will never have complete peace in our hearts. But one thing we will always have;  is peace knowing that we have done everything possible to give Reilly a voice and everything possible to make positive change to ensure that what happened to Reilly, and the pain our family and friends went through, hopefully does not happen again.

At every level of care Reilly and our family were let down in some way. We have peace knowing that through this Inquest process those errors were exposed and our hope for the future is that other families will be spared some of this pain by ways of prevention, through education, and unfortunately lessons learned.

We have faith knowing now that this Inquest process has done that in many ways.

We are extremely thankful to the Honorable Coroner; Dr. Jack Stanborough for his compassion, his integrity, his honesty and his wisdom and most of all his powerful words; “We speak for the dead to protect the living.” Those words will be etched in our hearts forever. Those words give us peace in our hearts knowing that someone was speaking for Reilly when she could not do so herself.

We are truly thankful to the Coroner’s Constable Mr. Bill Anand for his kindness and tentative nature and supplying us with anything we needed. We are deeply thankful to the Jury and the other council members for their time and great effort throughout this process. Families and friends were neglected temporarily and we do not get that time back, but change lasts forever and I believe we all accomplished that.

As a family we could never say in words how we feel about the support of members of our community, the local press and Reilly’s friends for their commitment and faithfulness to our family and most of all to Reilly.

Finally we want to specially thank Maureen Currie (who took on the role as the Anzovino/Kenney’s family solicitor at the inquest), her husband and family who have also suffered a great loss with their son “Kevin” one month prior to Reilly’s death.

 

Maureen was requested to represent us in this Inquest; partially through this process. We could not have found someone more capable, more dedicated and more honest to represent us and Reilly. All while still suffering from their own pain and loss.

We believe that fate did have a hand in assisting us to find Maureen and through this process she has helped to change our lives and many lives forever. For that we are truly grateful.

 

Thank you,

Now here are the recommendations, with headings to each of the agencies the jury hopes will adopt them. Be advised that Niagara At Large has placed in brackets the full name of agencies identified in the jurors’ recommendations with acronyms.

Niagara Health System

1. We encourage the NHS (Niagara Health System) to conduct a study in conjunction with the LHIN (Hamilton Niagara Haldimand Brant Local Health Integration Network) and in consultation with HHCS (Hamilton Health Sciences Centre) as to the feasibility of concentrating resources and trauma patients at one of the hospital sites of the NHS.

2. We encourage the implementation of a trauma alert code in the NHS (i.e. early notification system for mobilizing the appropriate medical personnel).

3. We encourage the NHS to continue developing a procedure for communicating information that is received from paramedics via radio patch that will ensure that the information is communicated quickly to nursing staff, including the Charge Nurse, in the emergency department.

Niagara Emergency Medical Services

4. We recommend that the NEMS (Niagara Emergency Medical Services) continue to collect “Load and Go” CTAS 1 and 2 patient care data for the purpose of ensuring completeness, accuracy, compliance with and educating paramedics about the importance of adhering to BLS and ALS standards. NEMS should continue its practice of reviewing any unwarranted or undocumented breach of these standards and make a consideration of appropriate action for any such breach that occurs without a reasonable and documented explanation. All reviews of CTAS 1 and 2 trauma patient care, where the care unreasonably fails to meet the BLS or ALS standards, should continue to be forwarded to the

Base Hospital Physicians and the MOHLTC

5. We recommend that a feasibility study be done about the possibility of installing video and/or sound recording equipment in ambulances for the purpose of quality of care review.

Ministry of Health and Long-Term Care

6. We recommend that the MOHLTC (Ontario Ministry of Health and Long Term Care), with input from MAC, should change the Field Trauma Triage Guideline to expand the parametres within which paramedics may choose to take a patient to a lead trauma hospital in Canada without having to seek approval from a Base Hospital physician to 30 minutes driving time from the scene (as opposed to time starting at patient assessment).

7. We recommend that the MOHLTC consider whether all of the Base Hospitals and Ontario EMS operators should be included within a patient’s “circle of care” such that they are entitled to share data on patient outcomes after patients have been delivered by paramedics to hospitals.

8. We recommend that the MOHLTC be encouraged to continue its efforts to develop a provincewide method for automated Computer Aided Dispatch (CAD) data transfer between provincially operated communications centres and regional or municipal emergency medical services, such that appropriate fields in patient care and/or ambulance reports will be automatically populated. MOHLTC should consider the best available data features from the NEMS communications model and incorporate them into the province-wide method.

9. We recommend that as an interim measure if the technology is already available pending the development of a provincewide solution for data transfer between the communications centre and electronic patient care reports of municipal or regional emergency medical services (as referred to in recommendation 8), we encourage the MOHLTC to allow NEWS to transfer Computer Aided Disptach (CAD) data automatically and electronically from the Communications Centre for Niagara such that the appropriate fields in the electronic Patient Care Report are automatically populated.

Ontario Emergency Medical Services

10. We encourage Ontario EMS operators to review their training and practices concerning means of capturing and documenting the nature and sequence of procedures and interventions used during patient care. We encourage use of any means currently available that may improve documentation, such as the use of event buttons on cardiac monitors. While patient care always takes precedence, such documentation may be valuable to quality of care reviews and researchers as data for evidence-based medicine. When current equipment is due to be replaced, consideration should be given to acquiring equipment that will assist in facilitating data capture in an effective and efficient manner.

11. We recommend that all Ontario EMS operators be encouraged to review whether there is a need for technology or other means of facilitating ease of communication between the driver of an ambulance and the paramedic who is providing patient care.

12 We recommend that all Ontario EMS operators ensure that all paramedics understand that “Load and Go” is an expected standard to be met unless exceptional circumstances exist. In any CTAS 1 and 2 cases where this standard is not met appropriate documentation and incident report should be filled out and provided to their base hospital for its consideration and ensuing review.

13. We recommend that it should be reinforced to all paramedics in Ontario that the BLS and ALS standards are not guidelines or motivators and must be followed as written; otherwise, provide documentation in the chart explaining why the standards could not be achieved.

14. We recommend that all Ontario EMS secure ambulance doors when on scene to minimize preventable delay.

Ontario Association of Fire Chiefs

15. We recommend that all firefighters who assist paramedics in providing patient care should complete a Medical Assistance Report (MAR) documenting their involvement in the care of the patient and should be forwarded to the local EMS operator to form part of the Patient Care Report.

Federal Minister of Justice

16. We recommend a review of section 254(2) of the Criminal Code to replace the requirement that peace officers have “reasonable grounds to suspect alcohol” with “any grounds to suspect alcohol” for roadside breath demands. This would assist peace officers in promoting road safety.

Ministry of Community Safety and Correctional Services

17. We recommend the MCSCS review the training delivered to all new police recruits in Ontario concerning drinking and driving. Training should emphasize the nature of the thresholds set out in the Criminal Code of Canada as to what circumstances or collection of circumstances may constitute “reasonable grounds to suspect” that someone operating a motor vehicle may have alcohol in their body such that a demand may be made by the officer for a roadside screening test. One of the goals of the training should be to encourage greater consistency in what constitutes “reasonable grounds to suspect.”

18. We recommend that if the review in recommendation 17 leads to an update in training new police recruits concerning the application of the Criminal Code thresholds for demanding a roadside screening test for alcohol, the MCSCS should notify all provincial, regional and municipal police services that they may consider updating their training in this regard.

19. We recommend that if police officers make one or more observations that may constitute reasonable grounds to suspect that someone operating a motor vehicle has alcohol in his/her body, but the officer exercises their discretion not to demand a roadside screening test, that the officer should document the reasons for that decision. For example, a test may not be conducted because the driver is unable to perform it due to their medical condition. The MCSCS and individual police services should develop a practice for review of such documentation. If it is not practical to do so in all cases, then the review of the documentation should occur in a timely manner in cases identified as being serious.

Ministry of Transportation

20. We encourage the MTO (Ontario Ministry of Transportaion) and the Region of Niagara to explore whether it is feasible to facilitate the sharing of information regarding road conditions on a real-time basis, so that deteriorating road conditions may be responded to promptly and thereby make driving conditions safer for motorists in the region, regardless of whether the province or region have responsibility for maintaing a particular roadway.

Hamilton Niagara Haldimand Brant Local Health Integration Network and MOHLTC

21. We recommend that this case be used as an educational example for base hospitals and all paramedic training in Ontario.

22. We recommend that the International Trauma Life Support (ITLS) continuing medical education program be mandatory for all paramedics across the province of Ontario.

Ontario Ministry of Training, Colleges and Universities

23. We recommend that the Ontario Ministry of Training, Colleges and Universities examine the curriculum of paramedic education in Ontario to ensure adequate education in trauma care.

Ministry of Health and Long-Term Care & Niagara Health System & Niagara Emergency Medical Services & ORANGE

24. We recommend all parties enter into discussions to determine the need, if any, for critical-care paramedic services for hospital to hospital transfers of appropriate patients in the Niagara region. The discussions should consider whether or not there is a need for ORNGE critical care land ambulance services to be available in Niagara region for appropriate patients, particularly when weather, darkness or other conditions may mean that ORNGE air ambulance is unavailable.

Ministry of Health and Long-Term Care & Base Hospitals

25. In addition to the “Load and Go” content contained in the ITLS course, we encourage the MOHLTC to review training and/or standards provided to paramedics concerning the “Load and Go Patients Standard” set out in the Basic Life Support Patient Care Standards. The review should ensure that the training and standards rely on evidence-based medicine. Any required medical interventions should be attempted enroute to hospital and should not delay the departure from the scene.

Ministry of Health and Long-Term Care & Regional Municipalities & Base Hospitals & Ontario Emergency Medical Services

26. We recommend that the Base Hospitals and/or MAC should be involved in quality review of care provided under both the BLS and ALS standards.

Ministry of Health and Long-Term Care & The Ontario Hospital Association & Ontario Emergency Medical Services

27. We recommend that efforts continue to ensure consistent criteria for CTAS scores used by hospitals and EMS throughout Ontario.

(We invite you to share your views below.)

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2 responses to “Coroner Inquest Ends With Recommendations Anzovino Family Feels Satisfied With

  1. A big IF !!

    Like

  2. Have any of these recommendations been completed?

    Like

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