The Pediatric Cardiac Surgery Inquest Report



The impact of the Maguire case

The Maguire case had considerable impact on the persons who participated in the operation. Within days, several of the participants took their concerns to Giddins, Craig and Postl.

Ward said that, while he had approved of the Wiseman Committee decision to proceed to offer a full service, including high-risk cases, he began to have reservations following the Maguire case. "I wondered at that time, which was towards early December, then I kind of wondered about the high risk surgery at that point in time." (Evidence of Dr. Ward, page 108) He wondered if there should not have been a different surgical approach in this case. He was also concerned that Odim and Swartz had given him differing accounts of what had happened to the cannula during the operation. Ward said that he communicated his concerns to Giddins. In his testimony, Giddins said he asked Ward to speak with Odim and straighten out this conflict. According to Giddins, Ward never reported back to him on the issue and he did not investigate the matter himself. Shortly afterwards, Ward went on vacation and when he returned, the program had been shut down.

Following Jesse Maguire's death, Swartz said, she was shattered and devastated. Within 24 hours, she spoke to both McNeill and Craig and expressed her concerns with the operation.

Youngson stayed off work the day after Jesse's death. She returned to work on November 29 and went to see Isobel Boyle, outlining her concerns with the program. Boyle arranged for Youngson and Hinam to meet with Postl. According to Youngson, Postl gave them a sympathetic hearing, but then told them what Youngson had been told by others. This was that Duncan had experienced similar problems in his first year and that it could be expected that not all high-risk cases would be successful. Youngson outlined once more her concerns about surgical technique and bleeding.

Boyle gave this description of the meeting with Postl.

So the three of us met with him the following day and Carol and Irene described the OR situation with him. And they-and when I would talk to them, you know, in terms of what can we do, I mean, they were so dedicated to going back for the children and the families, and that they thought if we don't go in there, what are they going to do?

Brian also asked them, he asked them if they wanted the program stopped; and it wasn't the program they wanted stopped, they wanted the incidences to stop. And he also asked them, what would make it-what did they think might make it better? And they said that certainly the cases that Dr. Hamilton had been involved in seemed to go better. (Evidence, page 32,709)

Postl recalled that the nurses made it clear that problems they had flagged early in the year were still present. Postl said:

I was struck by the intensity of their feeling about this situation. I was struck that they truly believed that these were very significant issues. And I was struck that they seemed very uncomfortable and, in fact, at least one of them was tearful during this description. (Evidence, page 35,544)

Casiro testified that he had expected Jesse Maguire to survive surgery. During the course of the Maguire operation, Casiro had spoken with Swartz, who had told him about the inadvertent removal of the cannula. Casiro subsequently spoke with Odim and was troubled by the fact that his version of the story did not mention the dislodging of the cannula and the problems encountered while reinserting it.

Casiro did not keep his troubled thoughts to himself. He spoke to Seshia about the conflicting versions and his own lack of understanding of what went wrong. He said he faced an ethical dilemma.

Well, it is sort of being torn between the loyalty or allegiance to the institution and the program, and to the patient and the family. And, you know, what is in the best interests of the patient, which is ultimately what we are advocating for.

And in my own mind, I start to question, asking, well, if I have this level of concerns, should I share this with the parents the next time I have a complex case that needs to have surgery? (Evidence, page 37,989)

Casiro indicated that he also spoke with Postl on December 2. (Postl placed this meeting three weeks later, on December 21.) He told Postl about his uncertainties with the program and said that he thought the issues regarding these cases (ID and Maguire) needed clarifying. He also told him about his ethical concerns.

According to Casiro, Postl told him he would speak to Blanchard. He also told him that he was seeking to have Lindsay review the program. Casiro said that Postl was jolted when he told him he was thinking of telling patients about his concerns.

Joan Borton was also becoming increasingly distraught over the outcomes. During this period Giddins encountered her at a time when she was in tears over events in the program. He told her that many people were worried about her. This shocked her. He then asked, "Are you with us?" to which she answered no (Evidence, page 18,243).

And I said to him, you think I should leave. And he said, well, yes. I said, well, I have been trying to leave. I have taken steps. Isobel has been involved. You know, it's just that I can't just do anything as a nurse. And he said, well, no, of course, you can't just do anything, but there are some things that you can do. And I went, well, why don't-what about if we have a meeting with Isobel. I will call Isobel and the three of us will sit down and really talk about what this is all about. And he agreed. (Evidence, pages 18,243-18,244)

The three met and a decision was made to find a term position for Borton outside the Variety Children's Heart Centre.

Hinam testified that by this point, she believed that no one who knew anything about the program would have allowed his or her own child to be operated on by this team. Hinam testified that she asked Kesselman if he would allow any of his children to undergo an operation in the Winnipeg program. She said at first he said he would not because he was personally acquainted with everyone involved. She asked Kesselman if that would still be his view if the Winnipeg surgeon were the best in the country. According to her testimony, Kesselman said that on that basis, he would allow his child to undergo cardiac surgery in Winnipeg. She said that other people involved in the program had said to her that they would not allow their children to be operated upon in Winnipeg.

The Wiseman committee didn't seem to have accomplished anything. And I just, I guess it was just like you felt like you were batting your head against a wall. (Evidence, pages 11,555-11,556)

In his testimony, Kesselman gave the following account of the conversation:

I recall that she kept asking me this, and I kept saying the things that I said to her, well, you know, that I think it's probably different for me, the inference being that if my child needed brain surgery or something, I might want to go somewhere else. And she kept on. I actually got quite irritated, and I just kind of said that to kind of end it, because she had asked me many, many times.

I think that probably wasn't the best thing to say. I think that was probably somewhat ill considered on my part. If this, you know, is to be taken as my views, other than really just a personal conversation. (Evidence, page 34,142)

Hinam testified that she went to see Boyle, who took her to see Postl. She said that she went to see Postl twice, once with Youngson.

I told him about this informal survey that I had taken, and how angry I was that we were continuing when people that didn't know any better, with only people that didn't know any better's kids. Because nobody that I talked to that day would ever let their children be done here. (Evidence, page 11,557)

In the wake of these discussions, Postl called Blanchard. He spoke with him about the concerns that the nurses and Casiro had expressed. One of the ideas that Postl and the nurses discussed was to have Hamilton present when Odim operated. Postl was impressed that the nurses had such confidence in Hamilton. Postl and Blanchard agreed that, for future cases, Hamilton would assist Odim. However, Postl could not recall if they had specified the kinds of cases at which this assistance would be provided. Postl thought that this would help to alleviate the concerns of those who had spoken with him, while he waited for Lindsay to arrive and review the program.

The dilemma that Hinam put to Kesselman was not always hypothetical. Donna Feser testified that a friend phoned her that autumn to ask about the program because a relative had a child scheduled to undergo surgery at the HSC. She asked Feser if she would allow this to happen if this were her child. Feser told her no.

I felt a moral obligation. And when I say I put myself in her position, I also was thinking, I was thinking of the child, I was thinking of the parents, I was thinking of the people that I had already seen go through this process, and seen the suffering, seeing the suffering of the Goyal family. (Evidence, page 30,042)

One cannot take issue with Feser's actions, which were taken on the basis of what she viewed as a moral imperative. However, when coupled with Borton and Hinam's testimony, it gives rise to two observations.

The first is that it would appear that people who had access to inside information were being warned away from the program, although these warnings were not being given or condoned by the program's leadership. Secondly, one is left with the sense that, just as Hinam had predicted in the spring, the program would have been subjected to a much more intensive review much earlier if the parents of the children who died had enjoyed greater socio-economic status and greater access to the workings of the hospital and the medical system.



Current Home - Table of Contents - Chapter 8 - The impact of the Maguire case
Next The case of JR - December 2
Previous Meeting of the department heads - November 28
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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