The family of a six year old Windsor, Ont., girl who died last July wants an inquest into her death.
They want to know how the Ornge air ambulance system failed to provide service to transport her to London.
Jamie Lynn Ingham was eventually taken to DMC Children's Hospital in Detroit, but by the time she got there, her condition had deteriorated so much that doctors couldn't save her.
According to a confidential cabinet report obtained by CBC News, the Ornge officer who received the request didn't log the call.
"I want everybody held responsible. I want everybody to know what they've done," said Ingham's aunt, Lesley Froome. "It's about our children's lives. It's about Jamie's life that was wasted by all of these people."
Ingham's parents are still too devastated to speak publically about what happened to their daughter nearly a year ago.
Ingham collapsed at home on June 30, 2011. She was rushed to Windsor Regional Hospital by ambulance at about 6:30 p.m.
"They said that Jamie Lynn had an aneurysm and that they were rushing her to London or Toronto hospital," Froome recalled.
A decision to request an Ornge transfer was made. The officer who received the request didn't log the call.
"The communications officer did not create a record of this request," the report reads, in part. "As a result, the flight planner was not able to review the request and determine the options available to service this request."
'They're on their way'
Hours dragged on at the hospital and Ingham's family became more desperate.
"Nobody would give us any answers," Froome claimed. "They just kept saying, 'they're on their way.'"
The family asked hospital staff to move Ingham to Michigan. Froome even offered to pay all the costs.
Froome claims one of the hospital nurses told her, "'you don't realize how much paperwork is involved."
"I don't care how much paperwork is involved we want her moved now," Froome said.
According to Froome, a black town car with several paramedics showed up at the hospital around 10:30 p.m. or 11 p.m.
Froome said she was "floored" that paramedics would arrive by car and not ambulance.
The hospital made the decision to send Ingham to Detroit. It took 10 minutes to get her there, Froome said. According to Froome, at 12:59 a.m. - six and a half hours after first arriving at Windsor Regional Hospital.
Doctors in Detroit diagnosed Ingham with meningitis. Her case was so far advanced by then that she couldn't recover. Ingham died July 2.
"This person that made the mistake at Ornge and didn't log the call, do they know what the consequences were to their actions?" Froome asked.
According to the confidential report, the Ornge employee who failed to log the call for Ingham's transport to London was given "remediation" and a note on their file.
Ornge will cooperate
Ornge said in an emailed statement it would cooperate if an inquest is called.
"First and foremost, we want to express our sympathies to the family of the patient. This is no doubt a very difficult time and our thoughts are with them," spokesperson Jennifer Tracey wrote. "If the Ontario coroner determines an inquest or review should be held into a patient transport involving Ornge, we would cooperate fully with that process.
"The people of Ontario should know that they have a responsive, skilled air ambulance service that is dedicated to the patients it serves and to continually working to strengthen and improve."
Citing privacy rights, Ornge said it is "limited in what we can say about this specific case."
The incident also moved Windsor Regional Hospital CEO David Musyj to call for an inquest. He also wants to opt out of Ornge service, making transfers to Detroit the first choice in Windsor.