Problems from the beginning

1993 had been a hard year for the Pediatric Cardiac Surgery Program at the Winnipeg Health Sciences Centre (HSC). The program had lost its director, its surgeon and all but one of its cardiologists. In retrospect it appears that there was confusion as to who was going to be responsible for monitoring and assessing the new surgeon's surgical performance. Finally, the hospital was in the throes of a large-scale structural re-organization that engaged the attention and energies of many key people involved in the Pediatric Cardiac Surgery Program.

Stemming partially from these difficulties, 1994 was to be a year of tragedy for all associated with the program. Twelve children died, conflicts arose among many of the people involved with the program and, by the end of the year, hospital officials had moved to suspend it. The program has never been restarted.

This chapter describes and discusses the events of the first four-and-a-half months of 1994, concluding with the events of mid-May 1994, when the entire group of pediatric cardiac anaesthetists at the HSC announced that they would not provide service to the program unless a review was undertaken. In particular, the chapter focuses on five children who died while undergoing, or shortly after undergoing, pediatric cardiac surgery at the HSC. Those deaths in particular seem to have been at the centre of the anaesthetists' decision.

However, the events of 1994 must be seen as being more than a series of discrete operations with successful or unsuccessful outcomes. While each child's experience with the pediatric cardiac surgery program was unique, a number of issues arose during the investigation of each case, and many of them repeated themselves. These include a lack of preparation and orientation before the resumption of surgery in February, the lack of attention to building and maintaining a functioning team, problems with decision-making (particularly in terms of case selection), questions of experience and skill levels, confusion over roles and responsibilities, a lack of monitoring of the program and a lack of post-operative analysis of problems.

These are complex and inter-related issues and they do not always lead to simple conclusions. For this reason, this chapter will also discuss in detail many issues concerning the structure and functioning of the Pediatric Cardiac Surgery Program in general, as well as examining five individual deaths.