The Pediatric Cardiac Surgery Inquest Report



September 30-the meeting of department heads

On September 30, Postl met with Blanchard and Craig. They provided him with a briefing of the history of the Pediatric Cardiac Surgery Program in 1994.

Later that day Postl wrote to Wiseman, asking to see a copy of the case reviews that had been undertaken by the Wiseman Committee (Exhibit 19, Document 257). On October 21, Wiseman responded that there had been no detailed minutes or records concerning individual cases.

The review was carried out specifically to look for problems and to look for common themes with respect to problems which had been encountered.

The individual case reviews would occur at the Mortality Review Committee, both at the College and hospital level. I believe these are subject to the Evidence Act and are essentially not available.

I can supply you with a list of cases and the associated mortality attached to that list which comprised the initial experience. This perhaps will be of some assistance. (Exhibit 19, Document 263)

This response once more underscores the inadequacy of the committee process. The committee had been mandated to look at the underlying questions of mortality and morbidity; yet, after recommending a return to full service, it had no records that could be shared with Postl. It is to Postl's credit that he expected that there would be case reviews and that he sought to familiarize himself with them. It should be noted that Wiseman's response (which came three weeks after Postl's request) would have left Postl with the erroneous impression that the committee had produced no documentation.

On the same date, Postl also wrote to Boyle, asking for an update on issues relating to pediatric cardiac surgery. Boyle never responded in writing to this request. However, Postl said that he spoke with Boyle about the issue a number of times and was made aware that nursing staff still had problems with the program.

Postl also testified that, as part of his orientation that autumn, he spoke with Giddins, who as acting section head for pediatric cardiology reported to him. Neither Ward nor Giddins expressed concerns about the program's ability to provide full service. Kesselman informed Postl that he was satisfied with the workings of the Wiseman Committee. Postl also spoke about Odim to Hancock, who told him that he was performing very well.

During the fall, Postl became involved in discussions with both Seshia and Kesselman about the possibility of centralizing post-operative care for pediatric patients who had undergone open-heart surgery. Seshia testified that the NICU staff did not believe there had been any increased morbidity or mortality as a result of any post-cardiac surgery children being treated in the NICU. However, she said, the NICU staff recognized that the interests of the patients were paramount. Since it was the surgeon's wish to have all the patients treated in the PICU, and since there was a low volume in the NICU, she said "it made sense to have them all looked after in one place by a smaller team of individuals." (Evidence, page 33,514)

On September 30, Seshia met with the NICU staff to discuss the amalgamation of post-operative care of pediatric cardiac surgery patients. At that meeting the NICU staff gave general approval to the proposal.



Current Home - Table of Contents - Chapter 8 - September 30-the meeting of department heads
Next The end of September: the nurses are distressed
Previous The September 28 meeting of the Wiseman Committee
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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