The Pediatric Cardiac Surgery Inquest Report



The decision to conduct a review

It was apparent to all at the meeting that the program was in serious trouble. As a result, a decision was made to create a review committee. This was known as the Pediatric Cardiac Review Team, or the Wiseman Committee, since it was chaired by Wiseman. The committee held its first meeting on May 18. In his testimony, Craig noted that in all his years in health care he had never seen a major problem addressed as quickly as this problem was. In retrospect, however, the committee may have been struck too hastily, as some important matters were not addressed.

The written direction given to the committee was to "deal with on-going issues related to the Pediatric Cardiac Surgery program in an effort to best serve the needs of the pediatric patient." (Exhibit 20, Document 278 B) It was understood that the committee would review the cases that had been performed to that point in the program, and would also work to address the concerns of team members. What was not clear was how and when the committee was to report back, and to whom it was to report.

The decision to establish the committee precluded referring the matter to at least two existing bodies: the Pediatric Operating Room Committee and the Children's Hospital Management Advisory Committee. These bodies were described in Chapter Four of this report. This decision was not unreasonable. The personnel on the Wiseman Committee had more direct knowledge of the issues under discussion than did the members of the Pediatric Operating Room Committee, while the Children's Hospital Management Advisory Committee was a product of the mid-year reorganization of the HSC. Its membership would not have had direct knowledge of events in the program; nor would they have had expertise in the field.

However, because the committee was created outside existing processes, it lacked a clear structure and rules of procedure. It was not clear what authority the committee had to change existing procedures or seek advice from outside experts.



Current Home - Table of Contents - Chapter 7 - The decision to conduct a review
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Previous The meeting in Bishop's office
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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