The Pediatric Cardiac Surgery Inquest Report

 

 

Table of Contents

Chapter 7

The Slowdown
May 17 to September 1994


Preamble
The meeting in Bishop's office

The decision to conduct a review
What to do about the existing cases?
Informing HSC senior management
Membership on the Wiseman Committee
Assessing the problems

Were the anaesthetists justified in their action?

Options not taken
Blanchard speaks with Odim

The issue of committee records
The first meeting

Preparing for the process

Nursing concerns
Communication
Morale
Role confusion
Anaesthetic concerns
Input into the decision-making process
Communication
Follow-up
ICU concerns
Surgical equipment/materials to be available in PICU for emergency and elective procedures in the PICU
Clarification of areas of responsibility in post-operative management and communication about patient status and proposed changes in therapy, both to the surgeon and from the surgeon
Surgery and Cardiology concerns

The anaesthetists agree to return
The Wiseman Committee begins its discussions
Corporate reorganization takes effect
The work of the committee during the month of June

The trip to Saskatoon (June 13-14)

The case of VM
The June 29 committee meeting
Conflict over out-of-province referrals
Swartz's notes
Craig and Odim meet

The case of Aric Baumann

Issues
Background and diagnosis
The decision to operate
Consent
Admission to the hospital
The operation-June 30
Post-operative course
Autopsy
Findings
Could Aric's pulmonary vein stenosis have been identified before surgery?
Would Aric have benefited from a heart-lung transplant?
Was Aric a high-risk patient at a time when the program was not undertaking high-risk cases?
Were Aric's parents provided with sufficient information to allow them to give informed consent to the procedure?
What was the cause of death and was it preventable?

Kim Duncan's visit
The case of SK
The case of KZ
The July 13 Wiseman Committee meeting
The July 27 committee meeting
Nurses and the Wiseman Committee

The issues raised by Odim

Communications
Team meetings
Post-operative care and anaesthesia
Odim responds to concerns about cannulation

The case of Shalynn Piller

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative status
The operation-August 1
Post-operative course
Post-mortem findings
Findings
Were Shalynn's parents provided with sufficient information to allow them to give informed consent to the procedure?
Should the program have undertaken this operation at a time when neonates were supposed to be sent out of the province?
What was the cause of death and was it preventable?

Pressure builds for a return to full service
The August 10 committee meeting

The tricuspid atresia case
Post-operative care
Forthcoming cases
The draft interim report

The interim report is distributed
The Wiseman Committee plans to return to full service
The anaesthetists agree to return to full service
The return to full service
Conclusion

Communication
Decision-making

 

Current Home - Table of Contents - Chapter 7
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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