The Pediatric Cardiac Surgery Inquest Report



The parents

Unfortunately no thought had been given to the families of the 12 children who had died in 1994. With few exceptions, they heard about the shutdown through the media. The news shocked and distressed them. For a number of families, the news was also disturbing because they had yet to receive what were, by then, long-promised autopsy reports. It was, in fact, only at this point that the Terziskis were informed that no autopsy had been performed on their son.

Not surprisingly, the families began phoning the Heart Centre and the media. For its part, the HSC realized that a response was necessary. Lois Hawkins and Cathryn Martens, co-ordinator of the Patient Representative Office, began contacting families, although in many cases the families had already contacted them. The families were offered the opportunity to meet with HSC staff.

From the evidence, it appears that the families of Gary Caribou, Jessica Ulimaumi and Erin Petkau were never directly contacted. Hawkins testified that she spoke about the events with representatives of a family services agency in Lynn Lake that was providing service to the Caribou family. Hawkins said that she was given to understand that the family was "all right." (Evidence, page 12,226). In her testimony, Charlotte Caribou said that she only learned about the shutdown by reading about it. She also testified that her common-law husband had made an unsuccessful attempt to reach Odim by telephone. Hawkins testified that she communicated with northern medical officials, who told her that the Ulimaumi family did not wish any further involvement with the hospital. That information was confirmed by Christina Kopynsky, Q.C., Counsel for the Inquest, who travelled to Inuvik to meet with the family. Barbara Petkau testified that she was not contacted by the HSC.

Contact was also made with the Stills, who chose not to come to Winnipeg for a meeting. The Bichels, Pillers and Terziskis also chose not to attend a meeting.

Meetings were held with the families of Vinay Goyal, Aric Baumann, Marietess Tena Capili, Ashton Feakes and Jesse Maguire. The meetings were attended by family members (and, in some cases, friends), Odim, Hawkins, Martyn and-depending on who had been involved with the case-either Ward or Giddins. At the meetings, the doctors would review the medical issues and the family members would ask questions. From the evidence that was presented, these meetings varied considerably in tone and nature. Laurie Maguire, the Tena and Capili families and the Feakes were not satisfied with their meetings. The Tena and Capili families described the meetings as 'a run-around', while others were frustrated that no one at the meeting was able to explain why the program had been shut down. Indeed, several testified that Odim and Giddins essentially told the families that they had no explanation as to why the program was being shut down.

It is clear that the program's history and the summer shutdown were not properly explained to the families; nor were they shown the Williams and Roy report, let alone advised of its existence. Finally, even when there were known facts that should have been brought to a family's attention, such as the suture narrowing that had been identified in Marietess Tena Capili's autopsy, this information was also not shared with the family.

There were also expressions of support for the program. Dr. J. Bergman, the pediatric chief resident, wrote Odim a letter of support on behalf of all the pediatric residents at Children's Hospital. Dr. Denis Hosking, the section head of Urology, also wrote Odim a letter of support.

Giddins received a letter of support from the Manitoba Pediatric Society on February 23. On March 7, 1995, Odim distributed an open letter to his colleagues. Along with it was an eight-page statistical summary of the program. In his letter, Odim wrote:

This information is in the public domain. It has been presented at our open year-end mortality and morbidity rounds. In addition, both the executive branch as well as concerned department heads have had copies of this information over the last two months.

As a matter of professional courtesy, you deserve to have an account of the program's activity during this period. The on-going media attention is affecting all of us at HSC. I am sharing the facts with you to clarify the rumours and distortion of the press. (Exhibit 20, Document 311)

In his testimony Thorfinnson testified that he was surprised by Odim's behaviour but took no action in response to his release of this documentation.

Letters of support were also sent to Odim from families whose children he had operated upon. In addition families whose children would now have to leave the province also raised their concerns.



Current Home - Table of Contents - Chapter 9 - The parents
Next The Quality Assurance Committee
Previous The role of the President and vice-presidents
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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