The Pediatric Cardiac Surgery Inquest Report



The family on the day of surgery

Ben Capili and Sarah and Teresida Tena were all at the hospital on the morning of the operation. According to Ben Capili, Lois Hawkins came out to speak with the family about the progress that was being made. Sarah Tena testified that Hawkins came to see them about every four hours. When they asked why the operation was taking so long, Sarah Tena recalled being told that the procedure had started late and there had been problems with unexpected bleeding. Teresida Tena also said that Giddins also brought the family updates on surgery during the course of the day. She testified that at 1730 hours Giddins informed them that there had been bleeding, but that it was under control.

Ben Capili testified that Odim came out of the OR to tell them that the operation had gone well and her blood flow was improving. As a result, they were told, Marietess would not have such severe cyanosis and would be looking less blue when they next saw her. Teresida Tena and Ben Capili also testified that, at the end of the operation, Hawkins told them that Marietess would no longer be blue when they saw her next.

When the family finally saw Marietess in the PICU at approximately 2100 hours, they were shocked. Her head was not only very blue, it was swollen. The nurse in the PICU told them that Marietess was in serious condition. No one spoke to them about her prospects. However, while they were at her bedside, an alarm sounded, and the nurse told them that they had to leave. The family left the PICU and waited for news. Sarah Tena was allowed to see Marietess after a while. Although Marietess was still heavily sedated, her mother spoke to her.

Giddins told them that Marietess was in critical condition. According to the family, however, there was no suggestion that Marietess would not survive the night, and Ben Capili and Teresida Tena went home. Sarah Tena stayed behind. When a nurse told her that Marietess's condition was getting worse, she phoned Ben Capili and Teresida Tena at approximately 0200 hours and told them to come back to the hospital. The family sat in the waiting room. Giddins informed them that Marietess's condition was poor and that it would take a miracle for her to survive. He came out one final time to tell them that she had died. A short while later, Odim came out to speak with the family.

Sarah Tena testified that, during the course of the whole evening, from the time that the operation was completed and Marietess was taken to the PICU, they had not been able to see her, except for a few minutes. The family, with some justification, believed that the seriousness of Marietess's situation was not properly communicated to them throughout the operation or the post-operative period.



Current Home - Table of Contents - Chapter 8 - The family on the day of surgery
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Previous Post-operative course
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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