Swartz conducted a pre-operative assessment that evening. She observed that Jesse's extremities were cool, his heartbeat was irregular and his chest was clear. She assessed him as ASA IV and indicated that he was at risk for arrhythmias, heart block, coagulopathy, paralysis and other neurological injuries. The morning of surgery, Jesse's condition remained relatively unchanged.

There was no evidence presented to this Inquest to suggest that there were any errors in the diagnosis, the pre-operative care or the surgical plan. Several consulting witnesses indicated that the one-stage repair that Odim chose is increasingly common, for the reasons that Odim advanced.