The Pediatric Cardiac Surgery Inquest Report




On August 22, 1994 Dr. Joseph de Nanassy performed an autopsy. A preliminary report was issued on September 7, 1994, but the final autopsy report was not completed until February 14, 1995. As a result, the Baumanns did not receive the autopsy report until mid-February. The delay in the completion of the autopsy report in this and a number of subsequent cases will be discussed in Chapter Nine. At the family's request, the autopsy was restricted to an internal examination of the chest and abdomen.

De Nanassy confirmed that, while the surgical repair was intact, Aric suffered from pulmonary vein stenosis. This was greater on the left side. The pathologist concluded that the pulmonary vein stenosis would not have been amenable to corrective measures. In his report, Taylor indicated that there was a tiny hole or fenestration in the patch. However, he testified that he could not identify when or how the fenestration was made, noting that in some cases, surgeons will make such a fenestration to ease pressures. The fenestration did not contribute to Aric's death.



Current Home - Table of Contents - Chapter 7 - Autopsy
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Previous Post-operative course
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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