All the committee members attended the first meeting on May 18, including Ullyot, who had become an additional member. Wiseman proposed the following terms of reference for the committee:

The team is to maintain an on-going review of the progress of the Cardiac Surgery Program with respect to quality of care, review of results, and to foster a spirit of comradery [sic] and good interpersonal team relationships in an effort to best serve the pediatric cardiac surgery patient. (Exhibit 19, Document 241)

The committee undertook to review all open-heart procedures that had been carried out from the beginning of the reactivation of the program in February 1994. Members were asked to prepare a written list of items that they felt needed to be reviewed and that were "relevant to their own area of participation." The committee agreed that:

The review items will be compiled and a case review will be carried out by the team, specifically looking for areas where problems may have been encountered in the past and to attempt to answer these problems in an equitable manner which is to be generally agreed upon by the team members. (Exhibit 19, Document 241)

Members were also asked to list problem areas so that the operating-room team's functioning could be improved. They were asked to produce a list of problems to be "discussed in an open format in an effort to resolve any and all issues that may have come up in the past. This is to be done in an effort to build a solid and unified team with a common goal." (Exhibit 19, Document 241)

Ullyot testified that she found it difficult to distinguish between the two sorts of issues on which Wiseman was requesting information, namely those areas that related to people's own area of participation and those areas where team functioning could be improved. This uneasy balance between areas of individual expertise and joint concern was to be a continuing stumbling block to the committee's work.

After considerable discussion, it was decided that for the coming six weeks, cases of a more complex/high-risk nature would be deferred. Patients who could not be deferred were to be transferred and, in particular, all babies with neonatal anomalies presenting as emergencies were to be referred to Saskatoon. Ullyot testified, however, that despite Wiseman's notes from the meeting, she did not believe the committee members had agreed that the hiatus would be limited to six weeks.

The May 18 meeting also laid out the ground rules for the committee's work. A number of the participants who testified had concerns about the limits on debate that emerged during the review.

One of the issues related to the instruction issued by Wiseman that committee members come up with issues to be reviewed from their own area of participation. McNeill said she felt that this instruction came from a desire to reduce tensions.

At this point in time, there was a lot of tension, there was a lot of prickly feelings amongst, particularly between surgery and anaesthesia, okay, nursing and surgery as well, less so perfusion and other people.

There was a great deal of emphasis put on the issue of communication. Communication being a major part of the problem, and if we can, you know, as they say, foster a spirit of camaraderie, that that would go along way to improving outcomes for the program.

So, the meeting, initially the meetings were I think all people, Dr. Wiseman set the tone, but most of us were aware that there were prickly feelings, if you will, and not to be confrontational, that that may not be very constructive to be confrontational.

And so I think that part of this comes from, I am trying to get at that this comes from that as a background, that people were encouraged to talk about what they were the expert in and not to necessarily comment on things outside their area of expertise, for the obvious reason, that they may be mistaken or that there wasn't a sort of a third hand, a third person corroborating or being able to validate their critique or their concerns. There was-so, that's where that I think comes from, that was my understanding of where that came from. (Evidence, pages 13,267-13,268)

McNeill said she also believed that the committee would also look at broader issues, but that this would be done in a general fashion.

What I am saying is that rather than coming in and saying on such and such a day you did such and such, and I don't think it was right, coming into the committee and talking about the issue of inadequate pump flows in two or three cases, or of post-operative bleeding in two or three cases. To bring an issue that had applicability across more than one case, and with the view to finding a response to that problem that would then benefit all the other patients in the program, coming to the program. (Evidence, page 13,269)

The decision requiring participants to comment on issues only within their area of expertise would place some restrictions on potential conflict at committee meetings-although the meetings were far from being conflict-free. However, it also meant that significant issues of concern to many members of the surgical team would go unaddressed. As will be seen, some committee members raised specific events that touched on areas outside their field of expertise but had alarmed or disturbed them. These persons had no independent means of validating their concerns and were given discouraging responses.

The committee's decision-making process was also flawed. The minutes of the meeting contain one statement about the process by which the committee would go about its work.

It was recommended that individual issues be dealt with so as to reach a consensus with all members of the team participating. It is proposed that specific principles of inter-team relationships would best be developed with this overall approach. It was recognized that there are many variables involved in the overall and complex issues to be dealt with however a uniform approach would help to clarify issues and make individuals better aware of expectations. (Exhibit 19, Document 241)

When McNeill was asked to explain what she understood by this paragraph, she said, "I don't understand a lot of what you just read, like what that means actually." (Evidence, page 13,277) She is correct: it is impossible to determine what sort of decision-making process that statement was proposing. McNeill said she believed that the committee was committed to consensus, as opposed to holding votes on each issue. However, there was no formal agreement or description of how consensus was to be reached. Consensus is not always a virtue, and in some circumstances it is impossible to achieve. If it is used to paper over deep division, it is not only not constructive, but can be destructive, fostering hypocrisy rather than honesty.

The focus on team building in the committee's terms of reference also made it almost impossible to address issues of competence. The review of the quality of care in the program obviously needed to be undertaken in a professional, non-vindictive fashion. However, given the strength of feeling that most of the people brought to the committee, it is easy to see that a discussion of members' concerns might, in the short-term, undermine, rather than enhance, interpersonal relationships.

Following the two-month period during which the anaesthetists and nurses had consistently expressed their concerns about the program's results to those people whom they believed to be responsible for the program, the decision of four experienced anaesthetists to withdraw services should have set off alarm bells in the offices of the HSC department heads concerned with the program. Ullyot had made it very clear in her meeting with Wiseman that the anaesthetists were concerned about deaths.

It is unfortunate that the anaesthetists had not felt able to take their concerns directly to Giddins and Odim before issuing their May 17 memorandum. It is also unfortunate that they had felt compelled to call for an immediate withdrawal of services-although in light of their serious concerns for patient safety, there was merit to that decision.

The anaesthetists had been justified in withdrawing their services. They had been faced with an ethical dilemma: they were expected to provide services to a program, yet they also had an overriding responsibility to the patients who were treated by that program. The questions they raised were valid. However, the process that was put in place could not address the questions that they raised-indeed, they felt constrained from even voicing those concerns in the committee.

Suggesting that a surgeon lacked the skills and experience to perform a particular procedure could hardly be called comradely; nor was it likely to be seen as an exercise in team building. Their withdrawal of services was an act of collective courage. Unfortunately, it did not lead to the kind of review that was required.