Background and diagnosis

Gary Caribou was an Aboriginal child, born on August 22, 1993, to Charlotte Caribou and Morris Dell of Lynn Lake, Manitoba. His birth appeared normal and without complications.

In November 1993, Gary's mother took him to the Lynn Lake Hospital because he was having difficulty breathing. A chest X-ray showed that he had pneumonia and Gary was treated with an antibiotic and a bronchodilator, both of which seemed to provide some relief for his wheezing and laboured breathing. Dr. Trevor Schlam also identified a heart murmur and referred Gary to Dr. M. Levy in Thompson. In his letter of referral, Schlam asked Levy to check for a congenital heart abnormality and further examine Gary's respiratory problems, which Schlam thought might be cardiac in origin.

Throughout Gary's treatment there were to be differences of opinion amongst all the doctors as to whether the respiratory problems that Gary experienced were solely attributable to his heart condition or if they were due to lung disease.

Gary was transferred to hospital in Thompson on November 30 and stayed until December 3, 1993. He was in respiratory distress and did not respond to bronchodilators or antibiotics. He was also diagnosed with failure to thrive. This is a state of poor health that describes a child's inability to grow and develop in a normal manner and is often associated with heart abnormalities. Children suffering from failure to thrive are susceptible to illnesses and diseases, in addition to the heart problems they might have. The condition needs to be closely monitored to ensure that the child does not deteriorate further.

Doctors in Thompson concluded that Gary had symptoms and signs of heart failure, brought on by a large ventricular septal defect with a fairly large shunt. Tests showed his heart was enlarged. He was treated with diuretics and seemed to improve, with a decrease in his respiratory distress. An appointment was arranged with the Variety Children's Heart Centre.

On December 17, 1993, Giddins saw Gary at the VCHC. By December 20, Giddins confirmed that Gary had:

• a moderately sized ventricular septal defect
• mild enlargement of both ventricles
• a muscular right ventricular outflow tract with muscle bundles.

He noted that there was a large left to right shunt, allowing blood to move inappropriately through the hole between the ventricles. Muscle bundles develop when portions of the heart are required to work harder than normal. These bundles can block or limit the flow of blood in an unhealthy manner, but in Gary's case, there was no actual obstruction to the outflow of blood from the right ventricle (or outflow tract obstruction). Muscle bundles also have implications for cardiac surgery, as their presence can make it more difficult to perform certain operations.

On examination in clinic, Giddins found Gary to be in heart failure. Gary's liver was enlarged. He was also small for his age, weighing only 5.5 kilograms, instead of an expected 6.5 kilograms. Giddins increased the dose of Gary's diuretics and also started him on digoxin, a drug used to treat congestive heart failure by strengthening heart contractions. Giddins did not recommend surgery at that point. He believed that if Gary was treated with aggressive nutritional support, he might grow out of the problem. While he suggested a follow-up assessment in two months, Giddins also added a caution: "The prognosis must be considered to be uncertain." (Exhibit 5, page CAR 2)

Giddins relayed his conclusions to the doctors who had referred Gary to him. However, there is no indication of what Giddins related to Gary's parents at that time. Charlotte Caribou testified that on this initial trip to Winnipeg, she was informed that Gary had a hole in his heart and that the options were to let it close on its own or to perform surgery. She said that Giddins essentially made the decision in favour of waiting. She returned to her home community with the expectation that she would be called back for another appointment.

Charlotte Caribou was not very knowledgeable as to her rights as her son's legal guardian, nor, if her conduct and demeanour on the witness stand is any indication, would she have been very assertive about them. She had spent most of her life in the remote Northern community of Mathias Colomb First Nation. While she was quite conversant in English, she had limited education, and spoke primarily Cree. Furthermore, she had had limited or no experience with this type of situation. As with many people, she said that she relied almost totally on the medical authorities.

Gary returned to Lynn Lake, where he was re-admitted to hospital on December 27, 1993. There he was treated for two months for failure to thrive and congestive heart failure. During this period, Schlam remained in touch with Giddins and the VCHC. Gary was unable to suck the volumes of formula required to increase his weight. A tube was therefore inserted through his nose and down into his stomach, so that larger volumes of formula could be given through the tube. When attempts were made to give him bolus feeds (or a larger volume at one time), Gary vomited. To prevent further vomiting, he was placed on continuous feeds through the tube into his stomach. This degree of forced feeding had limited success.

Healthy heart

Diagram 6.1 Gary Caribou - pre-operative heart 1 - Patent foramen ovale 2 - Right ventricular outflow tract obstruction 3 - Ligamentum arteriosus (former ductus arteriosus) 4 - Ventricular septal defect 5 - Abnormal right ventricular muscle bundles