The Pediatric Cardiac Surgery Inquest Report

 

 

Findings

As noted at the outset, this case gave rise to the following questions:

  • Was there an inappropriate delay between the time of Gary's diagnosis and the date of the operation on his heart?
  • Was his mother provided with sufficient information to allow her to give informed consent to the procedure?
  • Was Gary healthy enough to undergo an operation?
  • Did the length of surgery contribute to his death?
  • Did the post-operative abdominal drainage procedure contribute to his death?
  • What was the cause of death and was it preventable?

Was there an inappropriate delay between the time of Gary's diagnosis and the date of the operation on his heart?

One of the reasons for Gary's death advanced by the consultants engaged to review this case for the Inquest was his weakness at the time of operation. A question therefore arises over the wisdom of not performing surgery in December 1993, when the condition was first diagnosed. Although there was no surgeon available in Winnipeg to perform the operation, arrangements could have been made for Gary to be sent to another heart program in another province.

Giddins testified that experience had shown that in young children, small holes in the heart could close on their own, without any surgical intervention. At the time, Giddins was unable to come to a conclusion as to whether or not surgery was required or if Gary's defect might heal on its own. Giddins believed that the possibility of the holes closing on their own was preferable to surgery, particularly in light of Gary's already frail condition. As well, Giddins thought that Gary's overall condition could be improved with medical assistance.

Finding

Allowing a septal defect to heal on its own is a better course than closing it surgically. Surgery has many pitfalls, including a certain degree of risk-albeit sometimes small-of a fatal outcome. Giddins's decision to wait to see if the defect in the septum would close on its own was a sensible medical decision.

 

Was Gary's mother provided with sufficient information to allow her to give informed consent to the procedure?

Finding

No one told Charlotte Caribou that the surgeon had never before performed this type of surgery on this type of patient without supervision. She was unaware of the fact that the surgical team had performed only a very few simple operations together. Additionally, she was never told that her son's chest condition placed him at increased risk for the procedure he was undergoing.

All of this clearly might have influenced a reasonable person in her decision when giving consent to this operation being performed by this surgeon in this setting and therefore, should have been shared with her. The fact that this information was not shared tends to suggest that Gary's mother was not provided with sufficient information to allow her to give informed consent to the procedure.

 

Was Gary healthy enough to undergo an operation?

Several of the consulting witnesses who testified laid considerable stress on Gary's pre-operative condition. Cornel wrote: "The possibility of an important contribution to the demise by an intercurrent [ongoing] viral illness cannot be ruled out." (Exhibit 353, page 12) Dr. Walter Duncan2 concluded that Gary had experienced severe heart failure pre-operatively and died of lack of blood flow or low cardiac output post-operatively.

Finding

There is some evidence to suggest that Gary might have had a chest condition at the time that the operation was scheduled. While some significant features of an infection may not have been present (notably a fever), the evidence suggests that the surgeon and the cardiologist did not gather enough information to completely discount the existence of an infection.

Because of the tremendous importance that has been placed on the impact of infections on the recovery of pediatric cardiac patients, and the valid concerns raised about this issue by the consulting witnesses, Drs Giddins, Odim and McNeill should have ensured that proper tests were conducted to exclude the possibility of a chest infection before proceeding with the operation.

 

Did the length of surgery contribute to his death?

Considerable weight was also placed on the damage that was done to Gary by the length of the procedure.

Hudson wrote that:

. . . the need to leave the chest open because the patient cannot tolerate the hemodynamic effects of sternal closure is also more common after unduly prolonged CPB. Such severe cardiac failure in the early post CPB period suggests that there was significant myocardial injury during CPB. (Exhibit 307, page 1.14)

In their joint report, Cornel and Duncan stated that:

The etiology of the demise of this child remains uncertain. Contributing factors may have been an abnormal coagulation status, abnormal lung function and a relatively long surgical procedure. (Exhibit 354, page 2)

Dr. Christian Soder3 indicated in his report for this Inquest that:

The skill and dexterity of the surgeon performing these operations were insufficient for the challenge of successfully repairing infant hearts with complex malformations. Surgical factors were the prime determinants of fatal outcome in 9 of the 12 deaths. (Boldface in original) (Exhibit 345, page 8)

The case of Gary Caribou was one of the nine that Soder identified in which surgical factors were a prime determinant in a fatal outcome. In particular, he identified the lengthy bypass and cross-clamp time, and the excessive bleeding.

Finding

While a clear cause of death cannot firmly be established, it appears from the available evidence that the child was in a significantly compromised state when he entered the operating room, and the length of the operation seems to have been a significant contributing factor in his death. The evidence suggests that the length of the operation appears to have been directly related to the ability and inexperience of the surgeon.

 

Did a post-operative abdominal drainage procedure contribute to his death?

During the course of this Inquest, questions were raised about the peritoneal dialysis. The wisdom of the rapid drainage of a large volume of peritoneal or ascitic fluid was questioned by Cornel. In his view, given Gary's fragile state, any significant change in blood pressures would be difficult for Gary to cope with. In his written evidence, Cornel stated: "Rapid drainage of a large volume of ascitic fluid following the insertion of peritoneal dialysis catheter was associated with the final demise of the infant." (Exhibit 353, page 12)

The dialysis procedure involved draining ascitic fluid, injecting dialysis fluid into Gary's abdominal cavity, and then draining the dialysis fluid to relieve pressures and remove impurities. What was most important during the procedure was to ensure that there was close monitoring of any changes in pressure in the abdomen (from the fluid) on the function of the heart. This would appear as changes in heart rate and blood pressure. For example, a sudden increase or decrease in fluid pressure in the abdomen could produce a decrease in blood flow to the internal organs and to the heart itself. Thus, the key to the procedure was to ensure that flow of fluid into or out of the abdomen occurred at a rate that the heart could handle.

In many other facilities, including the Children's Hospital of Eastern Ontario where Cornel is the chief of pediatric cardiac surgery, a surgeon carries out the dialysis procedure on post-cardiac surgery patients, with the assistance of a nephrologist. In particular, Cornel said, it was important to limit the volume of liquid used and the rate at which it was drained.

Grimm testified that this was a procedure that he had performed many times previously and that in Gary's case he had followed all of the usual procedures. Grimm was assisted by Birk and by at least one PICU nurse. Neither Odim nor Hancock, (the intensivist on duty that evening) nor Dr. Ellsabete Doyle, the PICU resident, were present during the procedure.

Grimm was of the view that nothing done in the course of the dialysis procedure was a factor in Gary's death. He rejected any suggestion that the removal of fluid was conducted too quickly, pointing to the fact that while the initial fluid was being removed, Gary's blood pressure did not change, and there was no adverse reaction to the insertion of the catheter. He pointed out that the initial volume of dialysis fluid had been inserted and removed without incident as well, and that the second volume was in Gary's abdomen when Gary began to deteriorate. However, Grimm did not disagree with Cornel's view about the need to proceed slowly in the removal and replacement of fluids in this type of procedure.

Finding

It would appear that nothing Grimm did during the dialysis procedure was inappropriate. It is uncertain as to whether or not the dialysis procedure caused such a sudden change in Gary's blood pressure from which he was unable to recover. However, it would have been desirable for Odim or one of the intensivists to have been present while this procedure was being undertaken.

 

What was the cause of death and was it preventable?

It is unfortunate that an autopsy was not held. It will remain unclear if the medical issues that were part of Gary's demise could have been better determined. Coming to a conclusion as to exactly why Gary died will remain speculative, although there is sufficient information to reach some solid conclusions.

Findings

There is no suggestion that the surgical repair of the VSD was not successful. Although an autopsy was not performed, the available evidence suggests that the VSD was successfully patched.

However, the operation appears to have taken too long. The evidence suggests that the lengthy bypass and cross-clamp times may have significantly compromised the baby's chances of recovery. There seems to have been little more that could have been done for the baby post-operatively than was done in this case.

For these reasons, the evidence suggests that this death was possibly preventable.

 

2

Dr. Walter J. Duncan was, at the time of his testimony, a member of the staff of the Department of Pediatrics at the British Columbia Children's Hospital. A 1974 graduate of the College of Medicine at the University of Saskatchewan, Duncan interned at St. Paul's Hospital in 1975. From 1975 to 1982, he was at the Hospital for Sick Children in Toronto: as a resident in pediatrics (1975-1977), resident in pediatric cardiology (1977-1978), and clinical fellow in cardiology (1978-1979). He was certified as a fellow of the Royal College of Physicians and Surgeons of Canada in pediatrics. He was certified in general pediatrics by the American Board of Pediatrics in 1980, and was also certified by the Royal College of Physicians and Surgeons of Canada in pediatric cardiology in 1981. He held the positions of assistant professor of pediatric cardiology and pediatrics (July 1979 to June 1982) at the University of Toronto and was the section head of echocardiography during that time at the Hospital for Sick Children.

In 1982 he was appointed associate professor and then professor in 1988 in the Department of Pediatrics, Faculty of Medicine, University of Saskatchewan. He then was appointed professor in the Department of Pediatrics at the University of Ottawa and chief of the Division of Cardiology at Children's Hospital of Eastern Ontario.

In 1998 he was appointed to the Department of Pediatrics at the University of British Columbia and joined the staff of the British Columbia Children's Hospital.

He was acknowledged as having special expertise in pediatric cardiology and was permitted to give evidence to the Inquest in that area.

3

Dr. Christian Max Soder was born in Switzerland and graduated from the University of Alberta Medical School in 1975. He interned at the University of Alberta Hospital in 1976 in pediatrics, and was a resident in pediatrics in 1977. He took a position as resident in anaesthesia at the University of Toronto in 1977 and in 1978 was a resident in anaesthesia at the Toronto Hospital for Sick Children. In 1979 he became a fellow in pediatric intensive care at the Hospital for Sick Children and in 1980 was a resident in internal medicine at the Toronto General Hospital and a chief resident in anaesthesia at St. Michael's Hospital in Toronto.

A fellow of the Royal College of Physicians of Canada, he received a specialist certificate in pediatrics in May 1980 and a specialist certificate in anaesthesia in September 1980.

At the time of giving his evidence, Soder was on the full-time medical staff of Isaac Walton Killam Children's Hospital in Halifax, Nova Scotia, was an associate professor in the Department of Anaesthesia at Dalhousie University, a lecturer in the Department of Pediatrics at Dalhousie and chief of the Department of Anaesthesia at Isaac Walton Killam Grace Health Centre. He was also the director of intensive care at Isaac Walton Killam Grace and the medical director of the STARS NS (Shock Trauma Air Rescue Society) in Nova Scotia. He was a medical adviser as well with the Department of Respiratory Therapy at Isaac Walton Killam Grace. His publication and presentation list was extensive. Soder was permitted to give expert evidence with respect to anaesthetic and intensive-care issues that arose in a review of the cases before the Pediatric Cardiac Surgery Inquest.

 

 

Current Home - Table of Contents - Chapter 6 - Findings
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Previous Autopsy findings
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
Diagrams
Tables
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