The Pediatric Cardiac Surgery Inquest Report



Blanchard's meeting with Unruh and Odim - December 5

On December 5, 1994, after Postl had spoken with him, Blanchard telephoned Unruh. The call was to inform Unruh that, despite the efforts of the Wiseman Committee, there were still ongoing reports of problems in pediatric cardiac surgery. Blanchard said that it would be useful to involve Hamilton in the team to a greater extent. He asked Unruh to attend a meeting later that day, at which Blanchard would inform Odim of this decision. He wanted Unruh to be present at the meeting to provide support to Odim, who he thought would be demoralized by the decision.

Blanchard testified that while he thought that Odim needed help, Odim did not appear to feel he needed assistance.

And perhaps he hadn't thought about it, you know, and when you are in the middle of a swamp, you know, you are so busy with the alligators you may not think of everything, but he didn't seem to-what shall I say-I got the feeling or maybe he told me that he hadn't thought about that. (Evidence, page 36,638)

Odim himself testified that Blanchard felt having Hamilton in the OR was a means of having someone there who could see things from a surgical perspective and verify Odim's account of how the operations were proceeding.

On the day after this meeting, Blanchard sent Postl the following memorandum:

I met with Jonah Odim and Helmut Unruh on December 5th. It was agreed that Dr. Andrew Hamilton will assist Dr. Odim with all neonatal and all other high-risk cardiac operations. (Exhibit 19, Document 268)

Blanchard copied Odim and Hamilton with this memorandum, while Postl sent a copy of the memorandum to Boyle.

While there can be little doubt of the meaning of this memorandum, Odim testified that the memorandum did not reflect the agreement that had been reached at the December 5 meeting. In particular, he said, he understood that he was to have Hamilton's assistance for only open-heart neonatal cases and not for all neonatal cases.

Blanchard was asked what the memorandum meant by the phrase "all neonatal."

Well, I meant neonatal, I believe that is patients in the first month of life.

Q Certainly. I guess the question that's come up is, did you mean, did you mean all neonatal cases, including closed and open, which would-or what did you mean in that regard?

A Okay. I can't remember what I meant. I should have been more specific, but, I mean, the three of us generated this thought. The way it stands it would mean all neonatal, but probably what we had in mind was all open neonatal cases. (Evidence, page 36,639)

According to Unruh, at the meeting Blanchard informed Odim that the only way the program could be salvaged at that point was to have Hamilton present for "all of the major cases." (Evidence, page 35,210)

The difference between Odim's recollection of the agreement and the wording in the memorandum is particularly significant in light of Blanchard's response when he was asked to explain the purpose of the December 6 memorandum to Postl.

I think the memo was written for several reasons. One is to underscore with Jonah that we expect this, it isn't an option. And the other was to inform everyone else - it wasn't a problem for Dr. Hamilton, we knew that, just to inform everyone else that they would expect this to happen. And I think it would also serve to reassure Dr. Postl, who had told me that he had been informed that things went well, you know, in these complex cases when Dr. Hamilton was present. (Evidence, page 36,641)

It is difficult to square the clarity of the memorandum with Odim's and Blanchard's evidence. Postl initiated the request to have Hamilton present because of concerns that had been presented to him about surgical outcomes. The memorandum did indeed provide him and the nursing staff with a measure of assurance.

However, if Blanchard and Odim had not agreed to what the memorandum said, then it would appear that it was a false assurance. Either Blanchard worded the memorandum in a manner that did not reflect the understanding between Odim and himself, or-as the evidence in the later Petkau case suggests-Odim chose to disregard the memorandum. Blanchard was not clear in his testimony as to the nature of the agreement. It would have been appropriate if Odim or Blanchard had corrected the impression that was left by the memorandum. In light of their failure to do that, they ought to have abided by the written memorandum.

Giddins testified that he did not receive a copy of the December 6 memorandum; nor was he told of its specific contents. He did say that Postl informed him that formal arrangements had been made to have Hamilton assist at operations.



Current Home - Table of Contents - Chapter 8 - Blanchard's meeting with Unruh and Odim - December 5
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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
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