Air ambulance issues well known to government

Problems with the management of air ambulance services in the Cayman Islands were identified almost a decade ago, according to the former head of the 
Health Services Authority. 

Craig Brown, who led the HSA in 2006, said he had been working on a solution with government insurance firm CINICO amid concerns that the process was unwieldy and 
overly complex.  

A new system was agreed at the time but was nixed by government before it got beyond the planning stages, he said. 

Mr. Brown, who now lives in Canada, said questions had also been raised back in 2006 over the involvement of an air ambulance broker, Executive Air, and whether the ground handling services it provides for a $900 fee were 
actually necessary. 

His comments suggest that officials were aware of many of the concerns highlighted in a special public interest report by the 
auditor general last month, before the investigation was even initiated. 

Alastair Swarbrick, the auditor general, emphasised a range of issues with the process of flying seriously ill patients overseas for medical treatment. 

He said patient care could be jeopardised and the Cayman Islands government potentially exposed to lawsuits if the existing system continues. He pointed out that the air ambulance broker, named as Executive Air, had no direct contract with CINICO, no relevant trade and business licence and no permit to operate as a “ground handler” at the airport.  

Mr. Brown said he was unaware of the contract and permit situation in 2006 as the Health Services Authority did not deal directly with those issues. But he said some of the other problems highlighted in the report were well known to government long before he arrived on the scene. 

Mr. Brown worked with then-CINICO chief Gordon Rowell on a proposal that he says would have simplified the entire process and cut out the need for a middle-man completely. 

That proposal, which went as far as the tendering process before being shelved by government, would have involved the Health Services Authority dealing directly with a single contracted air ambulance company at a locked in price. 

The proposal would have radically simplified what was, and still is, a complex multistep process for arranging transfers. 

Right now, the medical director approves the transfer, he alerts the Health Services Authority, which is responsible for passing on the paperwork and medical notes to one of two private companies – a “third party administrator” and the “air ambulance broker”.  

Those firms, which have deferred responsibility from CINICO, then recruit from a network of air ambulance companies, largely based in the US, and arrange the transfer. This process involves a mini-tender of at least three firms to get the best price for any given job. 

A chain of emails, seen by the Caymanian Compass, show that both Mr. Brown and Mr. Rowell expressed concern about this process and pointed out that there were “deficiencies” in the system and potential for “breakdowns”, as well as implications in terms of “negligence liability” for the HSA. 

The new proposal would have simply involved HSA calling its contracted air ambulance firm whenever a transfer was required. 

“We were agreed that HSA should be the primary driver of air ambulance services because it is the HSA that has ultimate responsibility for the patient,” Mr. Brown said. 

He said the changes would have prevented patients in need of care experiencing long delays and cleared up any liability issues.  

He said the plan went to tender and there was significant interest from operators in the US, but government changed its mind midway through the process and opted to stick with the current system. He admits he “ruffled a few feathers” on this and other issues during his time at the HSA and was let go from the position after only eight months on the job. 

The auditor’s report, presented to the Legislative Assembly last month, also raised concerns over the use of the air ambulance broker as a ground handler. 

“We have not been able to ascertain why the ground handling service that is provided by the air ambulance broker to air ambulances are necessary,” Mr. Swarbrick wrote. “We understand from the Cayman Islands Airports Authority that the Air Carrier Operating Agreements, issued by the Civil Aviation Authority of the Cayman Islands permit the air ambulance carriers to self handle at the airport and they do not require the services of an air ambulance broker for this purpose.” 

Mr. Brown said this, too, was discussed during the 2006 process and he had come to the same conclusion. 

He said air ambulances were permitted to self handle and could, if they required, shop around to use whichever firm they liked at the airport.  

“There was no rationale for it then and I don’t believe there is any now,” he added. 

Edward Jerrard, an aviation expert and a lecturer at the University College of the Cayman Islands, has questioned this claim. He acknowledged that all ground handling firms should have relevant contracts and permits. But he said he believed that any aircraft coming into the Cayman Islands, such as an air ambulance service, would be operating under an FAA Part 135 certificate or equivalent and would need some form of ground handling service, not only to interface with the operator but between the operator and the hospital. 

No one from Executive Air had responded to phone calls from the Compass by press time on Monday. CINICO CEO Lonny Tibbetts said the company along with the HSA and the Ministry of Health would be issuing a joint statement on the issue “shortly”. 

Ambulance-at-airport

Concern has been raised over mismanagement of air ambulance services to fly seriously ill patients overseas for medical treatment. – Photo: Justin Uzzell
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