In declining to provide service to the program, the anaesthetists made it clear that one of their major concerns was that there did not appear to be any monitoring of surgical outcomes. It is legitimate to ask if they were correct in this perception.

There were M & M Rounds, where cases were reviewed, particularly those that ended with the death of the patient. However, as outlined in the previous chapter, these rounds had not proven to be effective forums for an overall monitoring of results.

If one asks "were those persons to whom Odim reported monitoring his surgical results?" the answer would have to be "No." No single person ever testified to this Inquest that he or she believed himself or herself to be responsible for monitoring the results of Odim's operations. Giddins said it was not his job to do so, Unruh said it was not his responsibility, Wiseman said it was not his, and Blanchard said he thought Giddins was doing it. Yet each of these persons had some responsibility to do so. The fact that they did not perceive themselves as having this responsibility was clearly reflected in the fact that none of them was expressing any concern about results by May 17, and also in the fact that no one else saw them taking steps to address what were seen as poor results.

The question can be asked in yet another fashion: "Were there events that should have been detected and addressed as the result of vigilant monitoring?" The answer, based on the testimony presented to this Inquest, suggests that there were several disturbing events that took place in the Pediatric Cardiac Surgery Program between February 14 and May 17 that a quality assurance program should have identified.

Five children died during this period. While fatalities are to be expected in this sort of program, the circumstances that surrounded the deaths of those children clearly suggested that problems in the way the program was being run, procedures performed, and decisions made, might have contributed to those deaths.

As noted in the previous chapter, Dr. Christian Soder indicated in his report for this Inquest that "[T]he skill and dexterity of the surgeon performing these operations were insufficient for the challenge of successfully repairing infant hearts with complex malformations." (Boldface in original) (Exhibit 345, page 8) Soder wrote that surgical factors were prime determinants of death in four of the first five deaths in the program. These factors included lengthy bypass times, the need to redo surgical repairs, the failure of repairs, problems with decannulation and excessive bleeding. These were issues that any quality assurance program could have detected.

There was also evidence from the operating nurses, the PICU nurses and the NICU nurses on the lack of planning, both for the restart of the program and for individual procedures. In addition, there is evidence that Odim did not understand a number of important HSC protocols-nor did he abide by them once they had been brought to his attention.

Before May 17, nurses and anaesthetists had concluded that speaking to Odim was futile. Those who had spoken with Giddins had perceived that he felt that there was no problem. Those who spoke to Wiseman had concluded that he also seemed to feel there was no need to be concerned about surgical results. While Bishop had asked Wiseman for information after Boyle and Ullyot had spoken with her, she had received information from Wiseman that suggested the problem lay with the complainants and not with the surgeon. While Bishop had asked Wiseman for more information, it was not apparent to either the nurses or the anaesthetists that she was doing anything about their concerns.

These events led the anaesthetists to conclude that the program was not being properly monitored. They decided that they were unable to provide services to the program because they felt that it might not have been providing an appropriate level of service and was not being properly monitored. This conclusion justified them in taking the action that they did.

The question of medical ethics is always a murky field to enter, and there are relatively few absolutes. However, something that comes closest to being absolute is the obligation of a doctor not to engage in conduct that he or she feels would be detrimental or dangerous to a patient. The anaesthetists had legitimate questions about the program and those questions had been put to people whom they perceived to be in positions of authority for the program-and their concerns were not being addressed. While they could have spoken with Giddins and Odim about their concerns, it was clear that Giddins did not agree with them, and that he, as well as Odim, were perceived as being part of the problem. The anaesthetists saw Giddins's workload as preventing him from paying appropriate attention to the monitoring that the program needed. The anaesthetists felt that there were questions of surgical competence that could not be addressed directly with the surgeon involved. All of this apparently caused them to conclude that the program might be doing more harm than good to patients, and that in order to address that concern, a review was needed. The only way they felt they had to bring the matter to a head was to address the issue as they did.