The Pediatric Cardiac Surgery Inquest Report




Marietess Tena Capili died on September 13, 1994, after undergoing surgery to repair a complex series of congenital heart defects.

The issues to which this case gives rise are:

  • Should the operation have been performed in Winnipeg or should Marietess have been referred out of province?
  • Were Marietess's parents provided with sufficient information to allow them to give informed consent to the procedure?
  • What caused the superior vena cava syndrome?
  • Should the surgical team have kept Marietess in the OR until the cause of the superior vena cava syndrome from which she was suffering was identified?
  • What was the cause of death and was it preventable?



Current Home - Table of Contents - Chapter 8 - Issues
Next Background and diagnosis
Previous The case of Marietess Tena Capili
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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