The Office of the
Chief Medical Examiner

As noted earlier, the death of any child must be reported to the Office of the Chief Medical Examiner. That was done promptly in each of the cases under examination. In each of the cases, a Medical Examiner Investigator made a timely visit to the HSC to look at the chart and to meet with Odim. The investigators differed from case to case, so that the same investigator was not involved in every case. That fact may have contributed to a slowness in the response of the CME's Office to the issues that were apparent from the cases. Apparently no trend in the deaths was noted, and information relating to the program itself and the changes that had occurred within it (including the arrival of a new surgeon) was not obtained. The fact that the anesthetists had withdrawn their services in May due to concerns over poor results, that there was dissension within the program, and that there had been a slowdown in the types of procedures the program was doing, had not been communicated to the CME's Office.

It is the policy of the CME's Office to authorize an autopsy when a child dies during or immediately after surgery. Parents are normally told of this policy. In the cases under discussion, the surgeon also requested the parent's permission to hold an autopsy. In the case of two children, Gary Caribou and Vinay Goyal, the families requested that there be no autopsy. Based on the Medical Examiner Investigator's report that there were no apparent issues with those cases, the Chief Medical Examiner chose to honour the family's request.

In the case of Daniel Terziski, no autopsy was held, despite the fact that the parents were amenable to an autopsy and the fact that both Odim and the Chief Medical Examiner's office believed that one should have been conducted. As discussed earlier, it appears that an autopsy was not held because of a failure of communication.

In eight of the twelve cases, the Medical Examiner Investigator concluded that there was no need for further investigation. In four cases, however, further investigation was authorized: those of Jessica Ulimaumi, Erica Bichel, Jesse Maguire and Erin Petkau. In the case of Jessica Ulimaumi, it was concluded that her death was the result of 'therapeutic misadventure' and the matter was referred to the Children's Inquest Review Committee, a multidisciplinary committee convened by the Chief Medical Examiner. The committee reviewed the matter and, aside from referring the file to the Paediatric Death Review Committee, took no other action. It should be noted that CME investigations usually take place following the completion of an autopsy. Aside from the Bichel case, the only other CME-ordered autopsy completed before the program was closed was that of Jessica Ulimaumi.

Upon reviewing the autopsy in the Bichel case, the Chief Medical Examiner did not refer the case to the Children's Inquest Review Committee. Markesteyn concluded that the circumstances of the death in that case did not warrant the holding of an inquest.

Throughout 1994 the Chief Medical Examiner was not aware of the events taking place in the Pediatric Cardiac Surgery Program. In addition, the Chief Medical Examiner's office was not made aware of the shutdown in December 1994. The Chief Medical Examiner was not informed of the review conducted by Drs. Williams and Roy, nor of its results. The Chief Medical Examiner's office was not consulted about the findings of the review; nor was the Chief Medical Examiner involved in the decision to suspend the program for a further period of six months.

Markesteyn testified that he became aware of the events in the program only when he read about them in the newspaper in February 1995. He then undertook further investigations and wrote to the HSC, asking for all documentation on the cases. The CME's office contacted the parents to inform them of the investigation. He contracted Dr. Walter Duncan to undertake a review of the deaths on his behalf. After receiving Duncan's report, Markesteyn consulted with members of the Children's Inquest Review Committee and decided that it would be appropriate to establish an inquest into the 12 deaths.