Company outlines how reduction of paramedics in air ambulance service poses safety risks
File picture: Larry Cummins
The company which provides a life-saving air ambulance service for the State raised serious concerns about flight safety risks after the HSE’s National Ambulance Service (NAS) introduced changes to the medical crewing model on the aircraft.
The crew changes included rostering just one paramedic to work some of the shifts on the aircraft, which operates from a base near Millstreet, in Cork, to covering the south west and beyond.
In an explosive email, a senior official in Gulf Med Aviation Services (GMAS), which provides the aircraft and pilots for the service under contract to the NAS, said since the changes:
- he had seen a marked deterioration in how the medical staff on board the helicopter perform their aviation tasks while tasked to work shifts on the helicopter;
- he had seen "workflow and cognitive errors" in the aviation-focused tasks the medical crew need to perform safely as part of the helicopter crew;
- and how the “low levels of motivation, concentration, and attention to the task” that appear to have resulted from the recent medical crew changes is “evident and impactful”.
Malta-based GMAS went so far as to formally ask NAS officials for “an intervention at the earliest opportunity” to address the issues, which were flagged in February.
The HSE has insisted, however, that the helicopter emergency medical service (HEMS) is safe and working effectively, that the crewing model is safe for both patients and crew, and that there are no outstanding matters of concern in relation to the contract.
The revelation comes just weeks after the reported how the HEMS covering the south was at risk of being grounded in a row over NAS moves to cut the number of paramedics rostered to work on the aircraft from two to just one. Farm safety minister Michael Healy-Rae described any such move as “reckless”.
The crewing changes were being advanced despite internal reports warning HSE and NAS management that a solo paramedic crewing model poses a risk to patients, to the paramedics and pilots, and poses a flight safety risk.
The Irish Examiner reported last March how one internal report warned that if the NAS couldn't provide two paramedics for each of the HEMS aircraft, then the service should be stood down on those days. The HEMS is currently operating several shifts with just one medical crew member on board.
A senior manager also warned that a single patient safety incident such as a drug error, an in-flight patient emergency, or in the worst-case scenario, a crash, would bring the crewing issue “sharply into focus”.
Concerns were also expressed in March that the NAS was recruiting emergency medical technicians (EMTs) to replace the second paramedic on the aircraft.
Qualifying as an EMT takes just five weeks. EMTs cannot perform any of the major “interventional skills” required to help critically ill patients, including intubation – the placing of a tube in a patient’s airway – and the intravenous administration of powerful painkillers, which are often required of patients who need an air ambulance.
The NAS provides two dedicated HEMS responses in Ireland - one based in Cork, operated by GMAS, and the other in Athlone operated by the Air Corps - with medical staff on both aircraft supplied by the NAS.
In 2022, GMAS won the competitive tender for the delivery of the Cork-based service, taking over from the previous charity provider in February 2023. It is understood the company won the tender again earlier this year.
GMAS has an aviation safety management system (SMS) which underwrites the approval of its HEMS service here by its regulator, TM-CAD, the civil aviation directorate in Malta.
But earlier this year, concerns were emerging from within the service about changes the NAS was making to the medical crewing model on board the aircraft, which included reducing the number of paramedics rostered to work the aircraft from two to just one on certain shifts.
In his letter to NAS officials in February, the GMAS official said the HEMS base in Cork had been operating for about two months with a limited medical team on the helicopter.
“It is important that as the operator of the service, we ensure our SMS processes are robust and commensurate with the acceptable risks that prevail during intensive HEMs operations,” he wrote.
“As we understand it, the advanced paramedics are generally spending seven shifts on the helicopter operation within a five-week period. The complex mix of other duties away from the HEMS operation further reduces their capacity to cope.
“As a result, Gulf Med is experiencing workflow and cognitive errors in the aviation centric tasks required of the paramedics that are critical for them to safely interface with the aviation side of the operation. In addition, the low levels of motivation, concentration, and attention to the task that appear to have resulted from the recent changes is evident and impactful.”
The company said safety is the number one consideration for all aviation operations and the regulations demand that due attention is given to the management of changes.
“In this case, the HEMs Rathcoole unit has seen three new HEMs paramedics very recently trained and allocated to the helicopter,” the GMAS official said.
“These individuals were trained and certified in a multi-practitioner role (two medical crew on board) and had barely consolidated before being rostered in the single practitioner role on the helicopter. The risks involved in such a change are self-evident.
“For example, a paramedic returning from a significant period away from the unit is often required to mount a HEMS mission in the first few minutes of arriving at the base. This is not a safe practice.”
It said like most safety critical activities, all that has to happen for a serious incident or an accident to occur, is for the good people involved to do nothing.
The Gulf Med official said he felt they were at the point where something needs to be done to improve:
- the recent experience of all staff on board the helicopter to match the risks involved in the operation;
- the mental capacity of junior members of the team to cope with the HEMs role;
- and a reduction in the disruption and changes that are clearly affecting the motivation, concentration and attention to detail that is necessary to remain safe.
GMAS did not respond to requests to comment.
Any issues relating to a contract like this, and which are being raised for resolution, must be raised by the relevant company through a formal contract management framework which has been established through the relevant public procurement process.
In a response to queries from the , the NAS said it takes concerns raised around the safety of its services very seriously.
“Any concerns or issues raised in relation to the HEMS are escalated through our agreed contract management process and dealt with expeditiously,” it said in a statement. “Currently the HSE and Gulf Med Aviation Services are satisfied that services are safe and working effectively.
“The crewing model for the HSE’s HEMS is safe for patients and staff. Since its inception in June 2012, the HSE HEMS has operated a successful crewing model consisting of one specialist paramedic and one EMT.
“In September 2024, the HSE commenced a feasibility study to examine the need for physician-delivered HEMS in Ireland. The preliminary results of the trial have not supported any change to the HEMS crewing model, hence the trial period has been extended into 2025.”
The HSE said both of its HEMS continue to operate normally, with further support, if required, provided through the Irish Coast Guard’s search and rescue aviation service.
