The Pediatric Cardiac Surgery Inquest Report




As noted at the outset, this case gave rise to the following questions:

  • Should the operation have been performed in Winnipeg or should Jesse have been referred out of province?
  • Were Jesse's parents provided with sufficient information to allow them to give informed consent to the procedure?
  • Should Dr. Andrew Hamilton have assisted in this operation?
  • Was a cannula inadvertently dislodged at 1630 hours?
  • Were all the repairs intact?
  • What was the cause of the poor perfusion following the initial repair?
  • Were Jesse's parents fully informed about the circumstances surrounding his death?
  • What was the cause of death and was it preventable?


Should the operation have been performed in Winnipeg
or should Jesse have been referred out of province?


The evidence tends to suggest that the team in Winnipeg should not have performed Jesse's surgery. To once more make use of Soder's assessment, the evidence suggests that:

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

This operation required considerable skill. Cornel called it a high-risk procedure, with a fatality rate of 15 per cent. In this case, Cornel concluded that "Technical errors were made in the course of this operation which precluded a successful outcome." (Exhibit 353, page 67) Specifically, he was referring to the problems with cannulation. In addition, Cornel stated that this condition is so rare that it takes a surgeon many years to gain experience in the appropriate care of such patients. In their joint report, Duncan and Cornel wrote:

Other technical issues relate to our questioning a relatively inexperienced team's capabilities to do technically difficult surgery on a neonate with a small aorta. Was the option of a remote referral provided? (Exhibit 354, page 14)

One can point to the following areas as evidence of the problems with the operation as performed in Winnipeg.

  • The length of the first period of TCA. Consulting witnesses who appeared before this Inquest indicated that a TCA of over one hour was almost certain to lead to severe damage to Jesse Maguire, even if the rest of the operation had gone smoothly.

  • The decision to repair the VSD on TCA. Given the length of time it took to repair the aortic arch, the evidence suggests that Odim should have conducted this repair on low-flow bypass. By failing to do so, he contributed to the overly long period of TCA.

In his testimony on this point, Cornel stated that he would repair a VSD on TCA only if he could keep the entire period of time on TCA under 45 minutes. In Jesse's case, the total initial period of TCA was 102 minutes. When Odim decided to proceed with the VSD repair, Jesse had apparently already been on TCA for over 40 minutes. Cornel acknowledged that it is easier for the surgeon to perform this portion of the repair under TCA, but it is also apparent that there is no benefit to the patient when the TCA is as long as it was in this case.

  • The difficulties in recannulating Jesse's aorta at 1630 hours. Recannulation, in all likelihood, initiated a series of events that led to the need to put Jesse on bypass and TCA for a second time, with fatal results.

  • The lengthy period of time that preceded the decision to separate from bypass and remove the cannulas. Hudson's report on this point is telling. He writes:

The attempts to separate from the first session of CPB lasted from approximately 1615 to 1800. If the team had diagnosed and treated the problems encountered during this time more expeditiously, the total time on CPB would have been shortened, which might have favourably influenced the outcome. (Exhibit 307, page 11.6)

In his testimony, Hudson was even more explicit, stating that during the 105 minute period the team determined that it could be the cannula that was causing the obstruction. That being the case, they decided to go off bypass and remove the cannula. After pointing out that in the chart Odim had observed that this was a known problem, Hudson testified, "my point there was that if this is a known problem, that it shouldn't have taken an hour and three quarters to develop a plan of management to attack it." (Evidence, pages 40,042-40,043)

  • The difficulties surrounding the removal of the cannula at 1810 hours. Odim indicated that he believed that the sutures he put in place after removing the cannula at 1810 hours might have continued the obstruction that he thought had originally been caused by the cannula. This required him to re-insert the cannula.

  • The difficulties in recannulating Jesse's aorta at 1842 hours. During recannulation, the initial repair was torn.

  • The length of the second repair. Witnesses testified that the length of the second period of TCA placed Jesse at considerable risk.


Were Jesse's parents provided with sufficient information
to allow them to give informed consent to the procedure?


Jesse's parents were apparently aware of Odim's relative lack of experience in performing this type of surgery in an unsupervised setting. Richard Shumila recalled Odim telling them that he had not done this type of procedure before, but that cardiac surgery was his specialty. The difficulty was, of course, that like most parents (and patients), it is difficult to know how to evaluate this information.

However, the parents were not told of the program's recent problems; nor were they offered the option of transferring their son out of province for surgery. In their testimony, Cornel and Duncan stated that it might well have been possible for Jesse to have been transferred safely. This should have been discussed with his parents. This evidence tends to suggest that Jesse's parents were not provided with sufficient information to allow them to give informed consent to the procedure.


Should Dr. Andrew Hamilton have assisted in this operation?


This was a high-risk operation that fit the criteria under which Hamilton was expected to assist Odim. Both Hamilton and Blanchard testified to this fact. Unfortunately, as noted earlier, the evidence is not clear as to whether this instruction had been properly communicated to Odim or to the rest of the PCS team.


Was a cannula inadvertently dislodged at 1630 hours?


While Odim and Hancock could not recall this event, the testimony of the anaesthetist, perfusionists and nurses, coupled with the anaesthetic and perfusion records, all suggest that this event took place.


Were all the repairs intact?


Phillips and Soder, in their reports, concluded that all of the repairs were intact. It is not possible to argue with that finding. However, that simply means that the repairs had not failed. Unfortunately, the repairs were never tested, as Jesse died without his heart having started to beat on its own.


What was the cause of the poor perfusion following the initial repair?


It is not possible to provide a definitive answer to this question. In his report, Cornel wrote that:

The difficulty with the aortic cannulation site may have been the result of poor positioning of the cannula, an unsuitable cannula or overly generous purse string sutures. (Exhibit 353, page 66)

In his testimony, Taylor said:

If the cannula or catheter is placed in a vessel that it may be too big for, it can strip the inner lining of that vessel and they form flaps as they are stripped back by the cannula or catheter. (Evidence, page 43,292)

Taylor said that the risk of this occurring increases if the cannula is inserted in a hasty manner, or if the cannula is too large.

The evidence from the autopsy also suggests that even after the initial repair, the aorta may have been partially blocked. The evidence suggests that, even if the aortic arch had been successfully repaired before Jesse died, it may not have been functioning properly before Jesse was put on bypass for the second time after 1830 hours.

All of the possible explanations for the subsequent problems with blood flow and pressure relate to surgical actions.


Were Jesse's parents fully informed about
the circumstances surrounding his death?


There are two issues that require comment about the information made available to Jesse's parents. The first is "what was told to them on the night of Jesse's death?" The second is "what was told to Jesse's doctor, Dr. S. Collison?"

As noted earlier, both Swartz and Youngson testified that they heard Odim tell Ward not to tell the parents about the problems with cannulation that occurred during the procedure. Swartz and Youngson interpreted this statement as an attempt to cover up the events that had taken place during the operation. Given their experiences, both in the previous year and on the day of the operation, it is not surprising that they put such a negative interpretation on Odim's comments. Neither Odim nor Ward were able to recall the instruction not to mention the problems with cannulation.

It should also be noted that Swartz and Odim gave Ward differing accounts of what had transpired during the operation. This placed Ward in a difficult position. It would not have been possible for him to determine accurately which account was correct at that time; nor would it have been appropriate to provide the parents with the account of either Odim or Swartz alone. It also would have been inappropriate for Ward to have advised the parents at that time of the conflict in the views of the surgeon and the anaesthetist. The best that Ward could do was to advise the parents that Jesse could not be weaned from bypass, and that more information would be shared with them when they were ready. This is what he did.

The evidence would suggest, therefore, that Ward's actions were appropriate to the moment. Similarly, if Odim's advice was simply that, on that evening, the parents should not be given detailed information about the events surrounding Jesse's death, then it was an appropriate instruction. However, the instruction was appropriate only as long as it was accompanied by an intention to be forthright with Jesse's parents when the opportunity presented itself.

Jesse's parents did deserve to receive a full accounting of the events surrounding Jesse's death. The evidence suggests, however, that they did not receive such an accounting.

In his November 28 letter to Collison, Odim neglected to mention the inadvertent decannulation that took place at 1630 hours. While Odim has testified that this event did not take place, the evidence suggests clearly that it did. It is difficult in fact, to determine why Odim continued to maintain, even while testifying, that the event did not occur, despite the overwhelming evidence to the contrary.

In his letter to Collison, Odim also stated, "despite what was a relatively smooth repair issues with cannula site obstruction necessitating repair and revision prolonging the circulatory arrest and total pump time clearly had a bearing on this child's outcome." (Exhibit 8, page MAG 22) The evidence-particularly the length of the initial TCA and the inadvertent decannulation-indicates that this was not a smooth repair.

The evidence also suggests that Odim did not give the referring doctor a full and accurate account of what occurred in the OR before the death of Jesse Maguire.


What was the cause of death and was it preventable?


Taylor, in his report, concluded as follows:

The proximate cause of the death of this child was myocardial injury resulting from excessively long circulatory arrest and cardiopulmonary bypass times. A major factor leading to the prolonged times was thoracic aortic obstruction complicating the initial repair of the interrupted aortic arch. This was thought clinically due to an aortic cannula that was felt to be relatively large for the abnormally small vessel, then subsequently to a stenosing aortic suture line. Attempts to correct this obstruction led to disruption of the anastomotic site requiring further circulatory arrest and cardiopulmonary bypass. (Exhibit 336, page 11.1)

Based on all of the evidence, the conclusion drawn by Taylor seems to be the correct one. The evidence suggests Jesse died because his heart had undergone an excessively long surgical procedure, from which it could not recover. The length of the operation was increased, it would appear, by the surgeon's inexperience, a dislodged cannula and an anastomotic tear caused by attempts to re-insert the cannula. Therefore, the evidence suggests that this was a preventable death.

The length of time that Jesse underwent total cardiac arrest also probably meant that, even if he had survived the operation, he would have suffered severe brain damage.

The tragic events of this case not only heightened the tensions in the OR, but soon became the subject of some discussion with the heads of the various departments.



Current Home - Table of Contents - Chapter 8 - Findings
Next Meeting of the department heads - November 28
Previous Post-mortem findings
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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