As noted above, this case gave rise to the following questions.

• 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?

Were Shalynn's parents provided with sufficient information to allow them to give informed consent to the procedure?

Finding

Odim's credentials were overstated to the family. The family was not told of the slowdown in the program; nor were they told of the problems that the program had experienced. Additionally, the family was not told that the program was not to do major neonatal anomalies such as their daughter had. The degree of risk presented by their daughter was not properly communicated to them. The evidence tends to suggest that Shalynn's parents were not 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?

Finding

The Wiseman Committee's May 18 decision was that neonates with major anomalies would be transferred to Saskatoon for operation. Shalynn should have been referred out of province instead of the team attempting her operation in the summer of 1994. The slowdown on May 17 had been initiated because there were concerns about the team's ability to manage high-risk cases. By definition, emergency operations in neonates were to be treated as high-risk. The evidence suggests that this case should have been referred out of province.

What was the cause of death and was it preventable?

Finding

None of the medical witnesses were able to offer a definitive explanation as to what happened to cause Shalynn's death. In their joint report, Duncan and Cornel wrote that "The etiology causing the death of this child is not clearly delineated." (Exhibit 354, page 9) Dr. Walter Duncan testified that he believed the banding might have increased Shalynn's sub-aortic stenosis, by obstructing the aortic outlets and by reducing the shunt. This made the sub-aortic area smaller and thus increased pressures on it. In addition, there would be an increase in the amount of blood leaking through the tricuspid valve. As the obstruction worsened, Shalynn's cardiac output fell. However, Duncan did not take any issue with the surgical approach that was taken in this case.

It is not possible, therefore, to say with any degree of certainty what the cause of death was, nor whether the death was preventable.