The committee met on August 24. The case of Daniel Terziski was discussed at this meeting. According to the minutes, the discussion led to revisiting the question of the post-operative care of neonates. The committee concluded that it should recommend that all open-heart cases be sent to the PICU, as opposed to the NICU. According to the minutes, the discussion of the Terziski case ended with the following conclusions:

The child went on to have ventilator dysfunction and proceeded relatively soon after return to the Nursery to have a cardiac arrest resulting in the need to open the chest and determine the patency of the shunt. The child expired and it was felt that there was no specific single component in the management of the patient which contributed greatest to the demise. Factors such as the prolonged arrest time were discussed, as well as the need to revise the shunt size. (Exhibit 20, Document 278 H)

Without belabouring the point, it is worth noting that the consulting witnesses to this Inquest identified a number of other serious problems with this operation. Duncan and Cornel questioned the wisdom of the team undertaking a Norwood procedure. This was also one of the cases about which Soder concluded that the

skill and dexterity of the surgeon performing these operations were insufficient for the challenge of successfully repairing infant hearts with complex malformations. (Bold in original) (Exhibit 345, page 8)

The inadequacy of the committee's approach is revealed by the extreme difference between the committee minutes and the reports prepared for this Inquest by consulting witnesses.

According to the minutes, after the discussion of a second case that was largely uneventful, the meeting turned to the cases that had taken place after the establishment of the committee.

The overall sense was that the results of the more recent experience have been satisfactory. Small problems have been encountered however the team communication and overall conduct of procedures appears to have improved.

It was further mentioned that there have been 4 cases carried out which are considered to be of an intermediate level of complexity and the results of these are also satisfactory.

Two deaths were mentioned including the death of a child in the Intensive Care Unit with previous repair of an ASD and the death of a child in the Intensive Care Nursery who underwent repair of a hypoplastic aortic arch.

The Team members recognize that there is significant pressure to increase the level of activity of the Cardiac Program and this of necessity will require the need to recommend in two weeks that the Program be allowed to continue at its full operating level. (Exhibit 20, Document 278 H)

It is useful to note the way that the return to full service was accelerated in the month of August. On July 27, it appears that a move to do medium-risk cases was turned down. By August 10, a report that recommends moving to full service in four to six months is accepted. According to some of the participants at the meeting, they expected the time line to be shortened in the final report. However, they did not expect it to be reduced to four to six weeks. Two weeks later, at the same meeting where the committee was informed of two deaths and reviewed the Terziski case, Wiseman informed the committee that he was recommending a return to full service in two weeks time.

The program had clearly been rushed back to full service.

Wiseman testified that when using the word 'pressure', he was referring to patient backlogs. When asked why the backlog required that the program return to full operating level, he testified:

This was, I think, this is awkward phrasing and, again, I am guilty of it here. I think that we had sort of agreed that in two weeks we would make a decision, or at least have a plan, so he could take away something in terms of when the program would be reactivated.

So that we were sort of trying to, I think, my sense was that the team was trying to posture itself to make a decision. And this was, two weeks was selected as a time to decide, to make a recommendation in two weeks whether the program was going to commence in another six months or three months or two months, so that Dr. Giddins would have some directive. (Evidence, page 40,650)

Wiseman testified that the statement in the minutes should be read as saying that in two weeks time a decision would be made about whether or not to return to full service.