The Pediatric Cardiac Surgery Inquest Report



The Quality Assurance Committee

The events in the Pediatric Cardiac Surgery program in 1994 were never discussed or reviewed by the HSC's Quality Assurance Committee, which is a committee of the HSC's Board of Directors. Thorfinnson testified that this was because the matter was not brought to the Committee's attention. He indicated that he believed that it should have been brought to the Committee. However, he also stated that he believed the Committee would have allowed the Department Heads to deal with the issue.



Current Home - Table of Contents - Chapter 9 - The Quality Assurance Committee
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Previous The parents
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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