The Pediatric Cardiac Surgery Inquest Report



Assessing the problems

Wiseman made notes of the May 17 meeting. These notes served as the basis for the committee's approach to reviewing the Pediatric Cardiac Surgery Program. These notes were not minutes as much as a summary of issues, and reflected Wiseman's assessment of the issues. According to the notes, the following points were discussed.

  1. Program results to date (Morbidity and Mortality).
  2. Need for a format for program members to vent their concerns and to discuss issues relevant to the program's success.
  3. The setting for post-operative care of all patients.
  4. The need to relate outcome data to the complexity of the anomaly.
  5. The need for the whole team to be able to share in the grief and disappointment which results from an unsatisfactory outcome.
  6. The need to recognize that interpersonal differences exist and should not be allowed to affect the program.
  7. The need to improve communication in a variety of ways.
  8. The need to have a baseline with respect to realistic expectations in the management of specific problems, especially in regards to more complex anomalies.
  9. Finally, it was recognized that there is a need to establish a "Pediatric Cardiac Program Team". (Exhibit 20, Document 278 B)

There are a number of comments that need to be made about the list that Wiseman created following the meeting.

First of all, besides the initial mention of morbidity and mortality, several of the points on the list suggest that the problem that needed to be addressed was the unwillingness of members of the team to accept the fact that some children in the program were going to die. Points 4, 5 and 8 all reflected this assumption. These points suggested that it was necessary to give team members a realistic baseline that would remind them that some children who underwent high-risk surgery would die.

Secondly, some points suggested that some team members needed special assistance in coming to terms with these tragic results. Points 6 and 7 suggested that some team members had allowed themselves to become enmeshed in personality conflicts and had lost sight of the program's overall goals. Through improved communication and by overcoming personal animus, this problem could be resolved. Point 2, with its stress on the need for a forum where team members could vent their concerns, also reflected this analysis.

Point 1 is simply cryptic: it spoke to the need to review the surgical outcomes, but it did not speak to who should have conducted such a review or what the existing concerns about those results were. The failing on this score is particularly dramatic when one considers the conclusions the College of Physicians and Surgeons of Manitoba's Paediatric Death Review Committee reached when it finally reviewed the five deaths that had taken place in the program to this point. The PDRC, which included Wiseman as a member, concluded that two of the five deaths that occurred by the time the anaesthetists withdrew their services were possibly preventable. The Wiseman Committee, however, came to no such conclusion.

Point 3 apparently spoke to the belief that post-operative care should be consolidated. However, it did not hint at the problems that the PICU and the NICU staff had with post-operative care.

In short, the notes reflected a view that there was nothing particularly wrong with the surgical outcomes. Rather, they suggest that a number of members of the team were seen to have unrealistic expectations and were unable to cope with the deaths of five children. As a result, they focused their hostility on the surgeon.

Not surprisingly, this analysis reflects many of the conclusions that Wiseman had earlier reached in his discussion with members of the surgical team before May 17.

Thus, the review would not have any external input and would not examine questions of surgical competence because it appears Wiseman had concluded that competence was not an issue. This meant that the committee would not address the very question that had led to its establishment in the first place.



Current Home - Table of Contents - Chapter 7 - Assessing the problems
Next Were the anaesthetists justified in their action?
Previous Membership on the Wiseman Committee
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
Search the Report
Table of Contents