Findings

As noted above this case gives rise to the following questions:

• Was Alyssa's family provided with sufficient information to allow them to give informed consent to the procedure?
• Was Alyssa healthy enough to undergo an operation?
• Were there technical problems with the operation?
• Was the PICU adequately equipped for her case?
• What was the cause of death and was it preventable?

Was Alyssa's family provided with sufficient information
to allow them to give informed consent to the procedure?

It is clear from the testimony provided to this Inquest that Alyssa's family had not been told about the recent deaths in the program. Based on the evidence, it would also seem that they would not have been told about the state of dysfunction of the operative team and the inexperience of the surgeon. In fact, there is some suggestion that information was passed to Alyssa's mother as to Odim's status within the profession that would not have been accurate.

Finding

It is reasonable to conclude that in the circumstances of this case, a patient or parent was entitled to know the true state of affairs of the program and that the team was not enjoying good results. The evidence tends to suggest that Alyssa's family was not provided with sufficient information to allow them to give informed consent to the procedure.

Was Alyssa healthy enough to undergo an operation?

Finding

The evidence presented to the Inquest raised questions about the decision to take Alyssa to surgery in light of a possible infection. However, the consulting witnesses in their testimony deferred to the decision that was made by Giddins, Odim and Wong. It is difficult to conclude, therefore, that their decision was an incorrect one.

Was the PICU adequately equipped for her case?

Finding

The events in PICU-including the need to call Youngson at 0400 hours-indicate that Odim had not yet ensured that the Unit was able to handle his patients postoperatively. These problems persisted, despite the efforts of the PICU staff to have the Unit properly equipped. Comments made by both Kiesman and Kesselman in testimony also raise questions about Odim's approach to his colleagues.

Were there technical problems with the operation?

Finding

The evidence suggests that Alyssa's coronary sinus was sutured closed, that there may not have been sufficient myocardial protection and that there was not sufficient relief of Alyssa's pulmonary stenosis.

What was the cause of death and was it preventable?

If Alyssa did not have an infection, there are unanswered questions about her death. While Odim indicated that her death was due to a vasovagal incident stimulated by suctioning, witnesses to this Inquest indicated that such a problem should have responded to pacing, which it did not. This leads one to question whether Alyssa's heart had been weakened during surgery or if the repair was not adequate. In his report Cornel also noted that there might have been inadequate relief of the pulmonary valve stenosis.

The questions that were raised about the lack of relief of the pulmonary valve, the suturing of the coronary sinus, and the presence of widespread edema, myocardial necrosis, and brain damage all suggest that it was during the course of surgery that Alyssa's heart was compromised to the point that it could not respond to pacing. Witnesses have also raised important questions as to whether or not there was sufficient myocardial protection during surgery.

Unfortunately, the records do not provide an explicit answer to this question. However, the damage done to Alyssa's heart suggests that protection was not adequate. In his report Dr. Walter Duncan commented that the three hour and seven minute pump time was lengthy. As noted elsewhere in this report, lengthy pump times led to an increase in post-operative problems.

Finally there is the failure of the pacing wires to assist the child to recover from the bradycardia that developed following the coughing spell. The wires should have worked, but either they were improperly placed or the heart was so compromised as not to be able to respond appropriately.

Finding

The evidence, therefore, suggests that the child died from compromise to the functioning of the heart brought about by a complicated and lengthy operation, and an inability of the heart to respond to pacing. Again, it is difficult to come to a definitive statement about whether or not this death was preventable. However, the lengthy bypass time, the possibly inadequate myocardial protection and the suturing of the coronary sinus suggest that this death might have been preventable.