One of the major criticisms of the committee process is that it involved a limited number of the people actually involved in the treatment of patients during the spring of 1994. Also, the committee focused on issues of teamwork, to the exclusion of competence and ability. Many of the people involved in the committee were reluctant to be completely frank about their concerns. However, it does appear that one member of the surgical team was prepared to raise these issues, but she was never asked to present her concerns to the committee.

Soon after the institution of the committee, Swartz prepared a four-page document outlining her general concerns with the program. She did this in anticipation of being consulted by the committee, however, the committee never undertook such a consultation, and therefore never heard her concerns.

The document (Exhibit 127) lists numerous concerns with the program that have been outlined in the previous chapter. However, it is worth reprinting Swartz's second point.

Are some cases of a degree of difficulty beyond the training, expertise, clinical experience and judgement (as a result of experience) of our surgeon. It is one thing to read about a procedure, another to see it, another to do it and another to do it well and recognize the difficulties and complications and know how to avoid or solve these problems.

I am referring to our high morbidity and mortality as evidence in themselves in general. (Exhibit 127)

These are strong words. One wishes one could say that it was simply unfortunate that they were never spoken at a committee meeting. But, in fact, it is far more than unfortunate. Swartz's comments represent the very issue that had brought about the anaesthetists' actions to begin with and permeated much of the thinking of some members of the committee throughout 1994. Silence on the point of whether or not competence was an issue allowed the matter to remain unaddressed.