The period from May 17 to September 7 constitutes a period during which the hospital undertook an internal review of the Pediatric Cardiac Surgery Program. That review was undertaken by a committee chaired by the director of pediatric surgery for Children's Hospital, Dr. Nathan Wiseman.

That committee suffered from a number of deficiencies from the outset. It lacked a mandate broad enough to address the issues that were being raised privately by anaesthetic and nursing staff. The committee lacked the personnel to conduct an expert assessment of the issues that were being raised. Finally, it does not appear to have developed a systematic approach to reviewing cases.

At the outset of this Inquest, the court was informed that there were no minutes for the committee. Yet, as the Inquest proceeded, minutes were in fact produced, in a piecemeal fashion. It appears, however, that there were some meetings for which there are no minutes.

Furthermore, the committee's interim report contains no assessment of the care that was given to children in the program, particularly to those children who died. The focus of the report is almost entirely on issues relating to communication and team building.

The committee did not develop any plan of action that would address the issues that had been identified. For example, there were no recommendations dealing with case selection, communication or monitoring.

At the same time, a number of cases took place during this period, VM and KZ in particular, that indicated that the issues the nurses and anaesthetists had been speaking of to their supervisors were still of considerable concern to members of the surgical team.

While McNeill and Youngson testified that they concurred with the decision to go back to full service, it is apparent from the evidence presented to this Inquest that they had very serious reservations and would have preferred not to return to full service at that time. However, the built-in failings of the committee structure left them with little option. The cases had been reviewed, and while it was stated that a consensus had been arrived at, it would be more accurate to say that a dominant view had been imposed.