What was clearly needed in May 1994 was an external review of the program, one that would be conducted by people who could assess the professional competence of all team members, as well as the team itself.

Soon after the program's problems began to appear, Odim and Giddins ought to have consulted with their department heads and put a proper review in place. That they failed to do so reflects poorly on their judgment.

By way of comparison, one can look at the evidence of two of the consulting witnesses who appeared before this Inquest. Dr. Gary Cornel and Dr. Walter Duncan were both active in the pediatric cardiac surgery program at the Children's Hospital of Eastern Ontario in Ottawa. Cornel is a surgeon there, while Duncan, for a time, was its senior pediatric cardiologist.

In Ottawa in 1992, six children died of what appeared to be respiratory failure after surgery. Cornel said that he found this to be a disturbing cluster of deaths. As a result, he consulted a coroner and slowed the program down to what he called a virtual stop. A review of the program was then carried out.

The review consisted of going over in detail everything about those cases with the pathologist, and trying to find common threads. In addition, we asked Dr. Bob Freedom from the Hospital for Sick Children to come and review the cases independently. And we asked him, especially because he is, as well as being a pediatric cardiologist, is recognized as a cardiac pathologist. So he was uniquely qualified to review the cases.

Having done the review and so on, we really didn't find any real common cause. The organisms involved were different, but pneumonia and infection was an important part of these cases. (Evidence, page 44,662)

Cornel said, that while no specific cause of the problem was ever identified, the review led to a number of changes and the problem did not recur. Once the review was completed, the program was restarted slowly, with the team restricting itself initially to what Cornel described as simple cases.

On May 17, when Bishop and Blanchard became aware of the anaesthetists' withdrawal of services, they also became aware of their concerns about morbidity, mortality and the apparent lack of monitoring within the program. From that time onward, Bishop and Blanchard had an obligation to ensure that the very serious issues of competence and patient safety, which such an extreme step as a withdrawal of anaesthetic services implies, were investigated fully.

Instead, they opted for what amounted to a debriefing and team building exercise. The process put in place after May 17, 1994, was intended to appease the anaesthetists, while getting the program back in operation as soon as possible.