The Pediatric Cardiac Surgery Inquest Report




Following the February restart of the program, there had been a major breakdown in communication. Nurses had spoken to their supervisors and anaesthetists, and to their division and department heads about the concerns they held with morbidity and mortality. The nurses and anaesthetists had also taken their concerns to Wiseman, who they believed was in charge of the Pediatric Cardiac Surgery Program. Wiseman chose not to observe Odim in operation. Instead, he appears to have discounted the opinions of the nurses and anaesthetists, and adopted the view that there were no surgical issues. From the way Wiseman structured the committee review, it appears that he interpreted the nurses' and anaesthetists' views as merely reflective of poor teamwork and their inability to deal with the deaths of patients.

The structure established for the committee may have been intended to build the team, but in reality it made team building impossible because the ground rules prevented the nurses and anaesthetists from raising issues that were most important to them. They could not effectively raise the issue of surgical competence because it was outside their area of expertise and because such a line of discussion went against the committee's goal of fostering camaraderie. In addition, the assistance that the committee needed to determine if the concerns of the nurses and anaesthetists over surgical ability had any validity was lacking.



Current Home - Table of Contents - Chapter 7 - Communication
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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
Table of Contents