The Pediatric Cardiac Surgery Inquest Report



The College of Physicians and Surgeons

As noted in Chapter Four, the College of Physicians and Surgeons of Manitoba (CPSM) created standards committees at all Manitoba Hospitals. In 1994 the Children's Hospital Standards Committee reported to both the HSC Centre-Wide Committee and the CPSM's Paediatric Death Review Committee. A panel of three surgeons reviewed surgical deaths in Children's Hospital and sent a report to the Children's Hospital Standards Committee. That panel did not make its report until the final autopsy on the child had been completed (in those cases where there was an autopsy). Once that report was prepared, Dr. Nathan Wiseman, a member of both the Standards Committee and the panel of three pediatric surgeons who reviewed cases, presented the report to the Standards Committee. The two other members of that panel were Odim and Dr. Postuma. Wiseman was asked if there was not a conflict of interest in Odim reviewing his own cases. He said in response.

It's difficult. This is the problem, there is no peer who is in a position of being able to be an expert in this area. We dealt with this for X number of years with Kim Duncan, where we sat down and reviewed cases with him; and it's dealt with basically by sort of challenging and asking questions and attempting to get objective answers, and trying to be satisfied that those answers are reasonable and appropriate.

There is definitely, I mean, if it gets down to the nitty-gritty, there is a phenomenon of mea culpa. People are very willing, maybe not always, but very willing to say, look, I screwed up. You have to recognize your own failings and put them on the table, and it happens.

. . .

THE COURT: You don't have a policy then of excluding from the committee a member whose cases are actually being under the review?

THE WITNESS: At the level of our sort of standards fact gathering to present to the hospital committee, no. At the level of the hospital committee, then there is no participation from the individual. The second level of review is-

THE COURT: That's Dr. Tenenbein's committee?

THE WITNESS: Yes. (Evidence, pages 40,748-40,749)

The fact that Odim was a member of the panel of surgeons that reviewed each surgical death for the Children's Hospital Standards Committee had the potential for a serious conflict of interest when the death involved one of Odim's patients. His involvement was called for because he was the only pediatric cardiac surgeon in Manitoba. A specialist in the field could have been brought in to assess the cases, thereby eliminating any potential conflict. That was not done in 1994, and the results of that process remain tainted by that fact.

The Children's Hospital Standards Committee would discuss the case and a report would be forwarded to the the CPSM's Paediatric Death Review Committee. There the case would once more be summarized and reviewed by the committee. Dr. Milton Tenenbein, the chair of the Children's Hospital Standards Committee, was also a member of the Paediatric Death Review Committee, as were Wiseman and Phillips.

All 12 deaths under consideration by this Inquest were reviewed in this manner. Those reviews did not take place in a timely manner. That was a matter of some concern to members of the section of pediatric anaesthesia. In October 1994 the pediatric anaesthetists wrote to both the panel of three surgeons and the Children's Hospital Standards Committee, urging them to expedite their review of the cases. Their concern persisted. On February 20, 1995, Dr. Carol Bachman, an anaesthetist, wrote a letter to Tenenbein on behalf of the pediatric anaesthetists, stating:

It is our hope that all children who had cardiac surgery and who died in the perioperative period be reviewed by the Standards Committee as soon as possible.

I realize that it is not uncommon for several months to elapse between a death and its review by the Standards Committee. Also, a separate review process had been instituted in the summer of 1994 for these specific cases, which may have delayed final review and recommendations, by the Standards Committee. (Exhibit 20, Document 295)

While it is not possible to determine from the evidence when the Children's Hospital Standards Committee reviewed each of the 12 deaths, it is clear that most of the reviews did not take place until after the program had been closed down in 1995. In his testimony, Wiseman testified that by January 1995 the surgical panel would have reviewed only those deaths that occurred before July 1994. According to a letter sent from the College of Physicians and Surgeons of Manitoba's counsel to this Inquest, by the date of the program closure the College had not assembled any data that would enable it to evaluate the program and/or form opinions about any trends (Exhibit 20, Document 360).

This suggests that, if the Children's Hospital Standards Committee had reviewed any of the 12 cases by February 14, 1995, it had not forwarded them to the Paediatric Death Review Committee. In his testimony, Tenenbein said that the committee attempted to deal with cases within six months during 1994. However he acknowledged that the process of review of the Paediatric Death Review Committee could be slow. In fact, he said (in response to a question about the length of time that the committee took to prepare its report), getting it out within two years of the year under review was considered a significant accomplishment.

In light of the public debate that followed the February 14, 1995, announcement, the Children's Hospital Standards Committee introduced new timelines. On March 14, 1995, Tenenbein wrote to Dr F.W. Orr, the head of Pathology for the HSC. The letter stated that the Standards Committee wanted provisional autopsy reports in 72 hours (unless it was a complex case when the deadline would be two weeks) and final reports in three months. If there were outstanding toxicology reports, the autopsy should be released with the caveat that the toxicology reports could change the final report. Orr agreed to the proposal. (Exhibit 322)

The Paediatric Death Review Committee issued an annual report for 1994 in January 1997. The report commented on all 12 deaths under review by this Inquest. The report concluded,

Of the 12 cases, the committee classified four as being possibly preventable with improved medical management. (Exhibit 156)

While they were not named in the report, the cases were summarized. It is apparent from the summaries that the committee was referring to the cases of Jessica Ulimaumi, Vinay Goyal, Marietess Tena Capili and Jesse Maguire. The report concluded that:

There is a lengthy delay in information reaching the College through the normal Standards route. There is a need for a timely, accountable, concurrent audit process at the hospital level whenever complex multidisciplinary programs of this nature are undertaken in children. Educational action at this point has consisted of letters to the physicians involved. (Exhibit 156)



Current Home - Table of Contents - Chapter 9 - The College of Physicians and Surgeons
Next The Office of the Chief Medical Examiner
Previous Delays in the autopsy reports
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
Search the Report
Table of Contents