The Pediatric Cardiac Surgery Inquest Report



January 1994

When Dr. Jonah Odim accepted a position with the HSC in November 1993, it was expected that he would take up his appointment in January 1994. His arrival however, was delayed until the beginning of February. Odim had to complete research work he was involved in at Harvard, as well as arrange a move to a new city. As an American citizen, Odim also had to acquire a work permit from the Canadian government. Before a permit would be issued, the HSC had to demonstrate to federal immigration officials that it had tried to find a suitable Canadian for the position and that there were none. At one point, HSC officials had to seek the assistance of provincial politicians to resolve the matter.


Orientation and integration

Dr. Robert Blanchard, head of the HSC Department of Surgery, and Dr. Agnes Bishop, head of the Department of Pediatrics, were the line managers responsible for the PCS program. The program faced the following difficulties:

  • The VCHC had only one cardiologist
  • The director of the Variety Children's Heart Centre was a junior cardiologist who only held the position in an acting capacity
  • The surgeon was at the start of his career and new to the HSC
  • There were no other pediatric cardiac surgeons on staff to mentor or monitor Odim
  • The rest of the surgical team had not worked together for six months.

It is worthwhile addressing the issues identified above in detail.

The VCHC had only one cardiologist

Where there had once been four cardiologists at the VCHC, there was now only one. That one cardiologist, Dr. Niels Giddins, had a large clinical workload and very few people to whom he could turn for support. He would have been extremely overworked for the first half of 1994, if his only responsibility had been to provide cardiology services. However, he was also the acting director of the VCHC.

Giddins was so busy that, even after the program gained access to a transesophageal echocardiography probe in 1994, he did not have the time to become familiar with its operation.

The director of the Variety Children's Heart Centre was a junior cardiologist who only held the position in an acting capacity

No evidence was presented to this Inquest to suggest that Giddins was ever properly prepared for the responsibilities that he had to shoulder when he took over the position of medical director of the Variety Children's Heart Centre.

The VCHC was largely the creation of Giddins's predecessor, Dr. George Collins. A senior cardiologist, with international experience, Collins had shaped the Centre and had been able to act as a mentor to the other cardiologists and to the previous surgeon, Dr. Kim Duncan. Perhaps without fully realizing it, the heads of surgery and pediatrics had allowed Collins to exercise monitoring functions that were properly theirs. It does not appear that anyone ever directly told Giddins that he was responsible for supervising surgical outcomes in the program, a responsibility for which he lacked both the time and experience. Giddins said that he was "never given a distinct list by Dr. Collins or Dr. Bishop of a formal set of administrative responsibilities." (Evidence, page 3,303)

Bishop did recognize that Giddins was being asked to shoulder a considerable burden, for she relieved him of many of his HSC and University of Manitoba duties.

The surgeon was at the start of his career and new to the HSC

Odim was not a newcomer to surgery. He had trained in a number of major urban hospitals in North America. However, he had limited experience as a primary surgeon, had rarely acted in a supervisory capacity and had never held a senior position before coming to Winnipeg. On the face of the evidence, it is clear that he had also always worked in large programs, with access to considerable resources. While the HSC is by no means a primitive institution, its pediatric cardiac surgery program did not have the same caseload nor the same resources as had been available to the program in Boston, where Odim had most recently trained.

As events developed, it also soon became apparent that there were institutional protocols at the HSC that differed from those in the institutions where Odim had trained. These differences were to lead to confusion and, at times, conflict, between Odim and the other staff at the HSC. These conflicts might have been avoidable with a proper orientation session, since it appears that Odim often became aware of the HSC's protocols only after the fact.

In some measure, Odim must take responsibility for this lack of familiarity with the HSC's limitations and differences. He ought to have taken it upon himself to become fully aware of the limitations and peculiarities of the HSC. He need not have accepted them; there may well have been good reason for change. However, as the service chief, he should have known of them before the team resumed surgery in February. In fact, in a number of instances, Odim rejected more than one opportunity to learn more about the peculiarities of the HSC or shape the program to fit his image of how a program ought to run. These opportunities will be discussed in this chapter.

However, of greater concern is the fact that no one in the HSC appears to have undertaken to provide Odim with an organized and systematic orientation. Duncan, Odim's predecessor, had not been asked to provide a written orientation that could be given to whoever succeeded him. Nor, it appeared, did Odim ever contact Duncan to gain any insight as to what he could expect in Winnipeg.

There were no other pediatric cardiac surgeons on staff to mentor or monitor Odim

Odim was also assuming a position that was unique within the structure of the hospital-one that lacked the usual support associated with surgery in other surgical programs. Neither Blanchard nor the acting head of cardiovascular and thoracic surgery, Dr. Helmut Unruh, were pediatric cardiac surgeons. The only experienced pediatric cardiac surgeon to assist Odim, if he should face any technical or clinical difficulties, was Dr. Jary Barwinsky, whose own experience did not include operating on neonates and small children.

In light of these issues, the situation in early 1994 therefore clearly called for a careful reintroduction of pediatric cardiac surgery. Attention should have been paid to both mentoring and monitoring Odim and Giddins, as they took on new and difficult responsibilities. Instead, it appears that in large measure both men were left to sink or swim. Blanchard, Bishop and Unruh did not appear to appreciate the sudden loss of the leadership role that Collins had played at the Centre. They appear to have assumed that the VCHC would simply continue to run without their direct involvement, even though it now had a new and overworked director.

There were a number of factors that contributed to the lack of attention paid to orientation. The major players overseeing the PCS program at the beginning of 1994 were either distracted by other matters or were under the impression that other persons were seeing to such an orientation. In addition, Bishop was immersed in other pressing issues, particularly the changes being implemented by the hospital as a result of the Curran Report.

In short, no one appeared to believe that it was his or her responsibility to plan for the orientation and integration of the new surgeon. As department heads, Blanchard and Bishop must bear the responsibility for this failure. In addition, both Unruh and Giddins should have taken steps to develop a planned orientation and integration. At a broader level, however, the administration of the HSC as a whole should have ensured that there was a more formalized orientation of new doctors. The practice of the HSC in 1994 was to leave such matters to the initiative of individual department heads. Many contemporary institutions, on the other hand, provide a more structured orientation for all new staff.

There was a second orientation issue that needed to be addressed. Not only was the changeover from Duncan to Odim poorly handled, but the changeover at the top of the Variety Children's Heart Centre from Collins to Giddins was also not well managed.



Current Home - Table of Contents - Chapter 6 - January 1994
Next February 1994
Previous The start-up
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
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