The Pediatric Cardiac Surgery Inquest Report

 

 

Table of Contents

Chapter 6

The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994, to May 17, 1994


Problems from the beginning
The start-up

January 1994
Orientation and integration
February 1994
The restart of the program
Team building
The nurses' attempts to initiate an orientation
Case selection
Summary

Surgery from February 28 to March 14

February 28-The case of ST
March 7-The case of DR - the first open-heart case
Odim's lack of familiarity with the OR setup
Odim's problems with cannulation
Odim's treatment of nurses

The case of Gary Caribou

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative condition
Conclusion as to Gary's pre-operative status
The operation - March 14
Post-operative course
Autopsy findings
Findings
Was there an inappropriate delay between the time of Gary's diagnosis and the date of the operation on his heart?
Was Gary's mother provided with sufficient information to allow her to give informed consent to the procedure?
Was Gary healthy enough to undergo an operation?
Did the length of surgery contribute to his death?
Did a post-operative abdominal drainage procedure contribute to his death?
What was the cause of death and was it preventable?
Post-mortem issues

The case of Vinay Goyal - his first operation

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative condition
The operation-March 17
Post-operative course
Overall condition
Breathing problems
Heart problems
Concerns of the nurses and the family
Decision to reoperate

The case of Jessica Ulimaumi

Issues
Background and diagnosis
The decision to operate
Pre-operative condition
Consent
The operation-March 24
Post-operative course
Autopsy findings
Post-mortem events
Findings
Was there an inappropriate delay between the time of her diagnosis and the date of the operation on her heart?
Was Jessica's family provided with sufficient information to allow them to give informed consent to the procedure?
Was Jessica healthy enough to undergo an operation?
Did the length of surgery contribute to her death?
Were the repairs properly carried out?
Did irregularities in the process of weaning her from ECMO contribute to her death?
What was the cause of death and was it preventable?
Should this death have triggered a review of the program?

The events of early April 1994

April 7 - the case of JM
Issues
Other PICU issues
Surgical monitoring lines
Post-operative bleeding and pacemaker malfunction
April 13 - the case of CSM

Vinay Goyal - the second procedure

Consent for the reoperation
Delay in the second operation
Pre-operative status
The operation-April 18
Intra-operative incidents
Dribbling of adrenalin on the heart
Testing the patch
The premature removal of a cannula
Autopsy
Findings
Were Vinay's parents provided with sufficient information to allow them to give informed consent to the procedure?
Would Vinay have been taken to surgery with a potential infection if his parents had not intervened?
Did the surgeon demonstrate the skills and experience necessary to undertake this high-risk surgery?
What was the cause of death and was it preventable?

Reaction of the PCS team following the deaths of Gary Caribou, Jessica Ulimaumi and Vinay Goyal

The response of the nurses
Perfusionists
Approaches to Wiseman
Anaesthetic meetings
April 18 - Meeting of the Section of Pediatric Anaesthesia

The case of Daniel Terziski

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative status
Preparing the NICU staff
The operation-April 20
Untoward events during surgery
Preparation of the homograft
Removing the cap from the line
Problems with the shunt
The assessment of the consultants
Post-operative Course
Autopsy
Findings
Should Daniel's condition have been diagnosed earlier?
Was Daniel's family provided with sufficient information to allow them to give informed consent to the procedure?
Was Daniel healthy enough to undergo an operation?
Should the HSC team have attempted the operation or should Daniel have been referred out of province?
Should there have been better planning for this procedure?
Did the length of surgery contribute to Daniel's death?
Was there appropriate post-operative care?
What was the cause of death and was it preventable?

What happened after the Terziski case

The results up to that time
Ullyot meets with Wiseman
Meetings in late April and early May
Nurses seek reassignment
Odim's view
The existing rounds and conferences

The case of Alyssa Still

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative condition-first admission
Pre-operative condition-second admission
Alyssa's admission to the Children's Hospital
The operation-May 5
Post-operative course
Did suctioning contribute to Alyssa's problems?
Autopsy findings
The presence of a suture in the coronary sinus
Contraction band necrosis
Edema
Cause of death
Findings
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?
Was the PICU adequately equipped for her case?
Were there technical problems with the operation?
What was the cause of death and was it preventable?

Borton asks for a transfer
May 11-12 - the case of FE
The case of RM
The anaesthetists withdraw services

May 16, 1994 - The meeting of the Section of Pediatric Anaesthesia
The May 17 memo from the anaesthetists
The distribution of the memo

Bishop is notified

 

  

Current Home - Table of Contents - Chapter 6
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
Diagrams
Tables
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